Nursing Notes Should Be Less Narrative, More Standardized, Article Says
May 30, 2012 | Risk Management News
Although free-text, narrative documentation of nursing care in electronic health records (EHRs) may always serve some role, relying on it as the sole or primary method of documenting nursing care generally “creates a scattered, redundant, and incomplete record of care that is not amenable for the analysis or improvement of care,” according to an article in the June 2012 Journal of PeriAnesthesia Nursing. An important benefit is that narrative documentation allows for clarification and explanation. However, if the profession continues to rely entirely or primarily on narrative documentation in EHRs, the knowledge-based aspects of nursing care will be “electronically invisible.” This could make it difficult to take advantage of EHRs’ increasingly sophisticated functions (e.g., data analysis to inform improvement). In addition, narrative documentation may be more susceptible to ambiguity, incompleteness, misspellings, transcription errors, and use of potentially confusing abbreviations (e.g., MS could mean multiple sclerosis, morphine sulfate, or magnesium sulfate).