Why Double Documenting Is A Bad Habit
Imagine being called into your manager's office. They sit you down and tell you that there is a problem.
The patient you took care of two weeks ago, who aspirated, has filed a complaint with the hospital that you didn't practice under the "standard of care." The complaint says that if he would have been placed in a higher bed position, he wouldn't have aspirated.
But you always keep patients like him with this condition at 45° or higher. Always.
It just so happens that during an audit of your charting, you happened to put 45° as a head of bed in your nursing note, but selected 15° in another area of the record for the same time. Because you noted two very different things at the same time, it's now a problem. You've violated one of the golden rules of documentation, which is to never double document!
Double Documentation - What is it?
Double documentation is the practice of denoting care (or inputting data) in two locations in a medical record. It's a totally unnecessary practice, and can potentially cause problems for the nurse, for the patient, and for the hospitalization.
Why It's A Problem
When we look at medical records as a whole, they serve several different purposes.
First, they serve as a record of care provided to patients.
Next, they serve as an ability for multid