SILVER SPRING, MD – Tuesday, the American Nurses Association (ANA), the Society for Pediatric Nurses (SPN), and the National Association of Pediatric Nurse Practitioners (NAPNAP), released a joint memo stating that all nurses must now document what information they are charting. This new guideline has implications across all specialties.
Now, instead of simply charting, “Patient rang call light for PRN pain medication, dispensed 1000 mg acetaminophen,” nurses are required to additionally document, “I am currently charting that I documented the prior statement: rang call light for PRN pain medication, dispersed 1000 mg acetaminophen.”
ANA President Karen Daley claims, “This will increase patient care and help reduce medical errors and overall improve patient satisfaction.” The ANA proudly boasts the greatest advancement in nursing is the ability to document more than they were able to even ten years ago.
“We are living in the golden age of documentation. With electronic medical records, charting couldn’t be easier,” Daley argues. “Now the hospital can bill for the time we spend documenting, but we must document that time to get credit.”
The new guidelines also state that hospitals using both paper and electronic medical documents, record when something is written down in the paper chart on the electronic record, and vice versa.
“Charted vital signs. Please see paper chart for the documentation,” followed by the vital signs. This type of documentation will also require two-nurse documentation where another nurse will have to document in the chart verifying the previous charting is correct.
Critics of the new rules say that they take away from actual patient care and it forces nurses to be transcriptionists instead of care providers. Daley disagrees, releasing a written statement where she stated, “These people [the critics] obviously do not work with patients. We want our nurses to provide the highest level of care and that is documentation. The more places nurses document patient information and the more often documentation occurs, the better for everyone. This is becoming the new standard of nursing and is superior to one-time documentation.”
This new regulation not only applies to inpatient care but is working its way into clinic nursing practice. The Joint Commission is in love with this new charting proposal and can’t wait to inspect paper and electronic records during their upcoming visits.
