How much is too much documentation?
Patrice L. Spath, of Brown Spath Associates, Forest Grove, OR, thinks The Joint Commission may have gone a bit too far with its growing emphasis on documentation.
"We consistently see the need to document things" she says. "For example, when a caregiver communicates in the hospital during a handoff and points out to the next caregivers the updated, reconciled medication list, they are supposed to document that they did it. We see similar things when discharge instructions need to be documented." This means, she explains, that you have to make sure there is a place in your record — be it paper or electronic — where people can document such activities.
Spath also points to the revised medication reconciliation goal, which she generally regards as a good move. "They have created another documentation requirement because you will now have a list of new short-term medications," she says. "You need to make sure you have a way of documenting, providing the new list to the patient, and documenting that you did that."
The same holds true with the new requirements for patient involvement, she continues. "It says the hospital should provide information to the patient about infection control and what can be done to prevent adverse events in surgery, but it's also another example where you gotta do it and then document it," she observes. "The patient's understanding must be evaluated and documented; it becomes just another check-off."
Again, she says, there is no way to determine if things have been done correctly. "If you put a brochure in with the pre-admission packet, you might conclude, 'We did it' and check off the box," she says.
The Joint Commission, she adds, "just keeps adding more and more [documentation]. People say this is just too much; everything seems equally important, since it all has to be documented."
But there is a bigger issue than time involved, she adds. "Just because you document does not mean the process has been done well," she says. "A good example is the Heparin overdose in Texas. Documentation does not stop mistakes if people are not doing things the right way."
Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission, agrees — to a point. "There is a general notion that just communicating and documenting does not guarantee that the patient comprehends," he says. "But that's why you also need to appreciate the level of comprehension the patient has. And, if there is a comprehension deficit, the organization should work toward correcting it."
Spath says The Joint Commission "continues to be focused on standardizing the way we do things. They have become much more prescriptive in their National Patient Safety Goals — but does that eliminate mistakes?"
In the end, she says, "it all comes back to the commitment of the staff to patient safety. If they do not think it's important, they may just report that they did the right thing."
"We consistently see the need to document things" she says. "For example, when a caregiver communicates in the hospital during a handoff and points out to the next caregivers the updated, reconciled medication list, they are supposed to document that they did it.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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