At least this is my experience. Doctors seldom read our progress notes (of course, there are exceptions to this), and even us nurses tend to read the doctors notes far more than we read our own colleagues documentations.
But when something goes wrong it is inevitably the nursing notes that come under scrutiny.
It is our documentation that is expected to provide the most meaningful measure of the standards of care delivery for the patient.
So as nurses, we tend to try to reflect both some sort of narrative of the patients journey through the health system as well as an objective record of interventions, care plans and issues.
sure we document, but do we communicate?
Many units/departments are transitioning to largely electronic record keeping applications, but as yet we are still using hand written nursing notes.
I was taught that the correct way to document my notes was to ensure there were no empty spaces or breaks in my writing (presumably so that nobody can retrospectively tamper or change the notations).
The feeling is very much……you know: give your care to the patient….but give your notes to the judge.
So a typical nursing progress notes entry might look like this.
Now, I’m not so concerned about content here (and don’t even get started on my spelling), but rather the overall visual connection of this set of notes.
It is based on a legal or organisational-centred design.
It is pretty much a block of dense text. It certainly does not convey much information on initial inspection.
You are going to have to wade right in and work hard to find anything useful.
I am not a lawyer, or a manager, or an auditor…so if I turn the page and see this, I am not engaged, and will keep looking for something to easily tell me what I want to know (often this is why I default to the doctors notes, because they seldom document in this way).
We have all experienced death by PowerPoint, well this is by Necrosis by Nurse Notation.
OK. Now, compare the first example with this one.
Exactly the same information, but presented with a little more artistic design:
- The information is set out to communicate information. It pushes information out to the reader rather than requiring them to pull it out of the page.
- It is user-centred and contains information cues, hierarchical organisation, emphasis and style and the use of space to improve accessibility to the information.
Now I ran this off very quickly, and with a little thought I am sure we could think of many other ways to improve the communication quality of our documentation.
For example: Use of colour. Use of standardised symbols to flag topics or themes. Use of ‘tags’.
This format may not stand up to the medico-legal requirements, but surely we have a far greater requirement to ensure that there is high-quality communication of information between ourselves?
What do you think?
What about the move to electronic notes?
Well, I kinda like handwriting my notes. It is like a personal seal on the care I have given to my patients. It is a little craft to reflect the art and science of my work.
Despite this, I have no illusions that hand written notes will soon be obsolete in many hospitals.
And there are certainly many advantages to maintaining data this way (lets just hope doctors don’t get to design their own fonts!).
But even with electronic record keeping, are we still communicating?
Is information presented in an accessible, user-friendly, visually engaging and contextual format?
Is the record of our care easy to get in and easy to get out?
There is certainly the design technology to do this. We must create the demand so that technology works for us.
An emergency department nurse at a major teaching hospital in Australia with 29 years clinical experience.
Ian has a special interest in the development of mindfulness and non-technical skills to build resilience, quality, and excellence in nursing practice.
He lives in Canberra, Australia with his partner Kelly, and their dog Smudge.
- Virginia says:
April 4, 2016 at 9:27 amGreat article. I was a patient and victim of serious medical negligence resulting in a medico legal case and medical board investigation twelve years ago. Sadly the documentation was woeful which caused enormous stress to me, because as a Nurse I knew something was wrong but many things were not documented. Our patients, just like me, face the threat of potential bankruptcy if they lose their medico legal case. I dread the day when we go to electronic notes – I
November 13, 2015 at 11:58 am
In the ICU that I work, We haven’t started electronic charting. Nurses used to do elaborate charting of head to toe assessment in the progress notes. We have an 8 page critical care flow sheet with checklists and chart for vitals and nursing care. Now nursing documentation on the progress note is more of a documentation by exceptions were you only document abnormal findings and daily events which makes it easier to look for informations. We are only allowed to use black and blue pens for documentations.
November 4, 2014 at 11:36 am
This is a great blog Ian thank you. Yes we need to document what we observe and do in a shift, but so often we I go to read notes to find some information needed I find that it’s not there. We absolutely document as a way of defense rather than communicating – for if we did communicate through our notes then we would be documenting in consideration for all of our colleagues. I am as guilty of this as anyone. I love the second entry style and will start doing this myself I feel. Why not add some creativity back into a task that’s deemed drab but necessary.
September 12, 2014 at 7:53 pm
I’m in a hospital that is going paperless and I miss the process of writing my notes. The other challenge is that when in a MET call, logging in to your electronic system poses a definate delay at a very critical time. It’s still early days but this is going to take a lot of getting used to!
November 21, 2013 at 8:41 am
Great post – this comment is very late but I haven’t had a chance to reply until now – As a community nurse, our notes are often all we have as ‘handover’ between the nurses caring for our clients – we have recently changed the way we document and plan care back (?) to SOAP using headings (subjective ‘what they say’, objective ‘what you can measure’, assessment, plan and add evaluation of actions/interventions where needed). we still write in ‘blocks’ but it is broken up under the headings which does make things easier for the eye to follow! The plan for the client’s over all/long term goals, as well as short term ‘next visit’ goals can be found quickly.
Thanks for a great post questioning the ‘why’ of what we do.
Penny Wilson says:
October 27, 2013 at 1:07 pm
Hi Ian – thanks for a very thoughtful post.
As a doctor, I obviously have my own biases but I completely agree with you that nursing notes with their dense block of text are not easy or inviting to read. Also – it promotes the writing of lengthy descriptive paragraphs rather than succinct phrases.
It seems that most doctors (and certainly I do myself) tend to write dot points, lists etc with lots of white space. This might be more medico-legally risky but certainly makes it more efficient to extract information.
The other point is about the purpose of the notes, and a lot of times it seems to be ass-covering. As a junior hospital doctor it would drive me crazy how many times nursing staff would diligently document “Doctor paged at 0815, has not yet attended” “Doctor paged again, has not yet reviewed the patient”… there was no mention of the fact that the doctor was resuscitating 3 other much more urgent patients, and had given verbal instructions for the care of the patient in the interim. That’s medico-legally a bad look, too.
Or the other problem is when people diligently document but don’t act! I’ve had examples when post-partum patients have had their seizures documented (very neatly with time, duration, vital signs etc) at 0615, 0635, 0650 – but no one thought to call me (the on call doctor) until 0705!
I’m by no means suggesting that documentation problems are limited to nurses. In fact, I think that doctors on the whole are probably FAR worse at documentation. Particularly, illegible handwriting, lack of clear management plan or, worse yet, failure to write any documentation in the notes at all.
It’s an important issue that certainly is worthy of discussion. Well done for starting the conversation.
September 13, 2014 at 4:57 pm
I completely agree about diligent documentation but no action until later being an issue. However to address the notes mentioning paging of Doctor many times who has yet to attended, you have your notes from those 3 other resuscitations you were attending to support evidence of delayed action if scrutinised. Nurses only have that one patients notes in which we need to demonstrate, if scrutinised, why care was prolonged. If no mention of paging the MO, who still hasn’t attended, that’s our neck on the line for negligence.
October 12, 2013 at 7:17 pm
A good case for good documantation. Well written and laid out notes are a great help for other members of the team looking after the patient.
Unfortunately my hospital has moved onto electronic notes with drop down boxes, which don’t give you enough options. Result: easy for the computer to print out statistics for the management team. Unfortunately those statistics are wrong, as the drop down boxes haven’t got all the answers, thus forcing you to choose from a range of wrong answers. Its not even covering you legally, let alone communicating well. Ends up you spend more time on documentation, making up for the poor choices in the drop down boxes, and less time actually looking after patients.
Lynn Wakeham says:
December 21, 2013 at 4:39 pm
That’s a real worry, as a former Ward Clerk, also the mother of a profoundly disabled child, the thought that doctors nurses are being ‘forced’ to go electronic with a program that doesn’t meet their expressive needs is not in anyone’s but most definitely not the patient’s best interests.
Kim Clinen says:
October 12, 2013 at 6:42 pm
I agree the 2nd set of notes is visually more pleasing and easier to find info, however my concern lies with the amount of space available for another to ‘fiddle’ with them. In dinosaur nursing school we were told to leave no spaces to avoid someone placing an unwanted addit. Years ago, I was involved in notes altered/missing and returned when the shit had hit the proverbial. It wasn’t a good look. kimmie
October 12, 2013 at 5:53 pm
Ian a great example for us Paramedics too, however as you well know we have changed to electronic PCR (patient care reports) this has good and bad points. Good points: Easier to draw down data and statistics, immediately on “the system” , plenty of prompts, spell check, consistency of documentation. Also computer print out means your not interpreting writing . Bad points: slow+++, system failure, poor understanding of how to use technology means important facts not entered, lacks personality of information, how information presents for those that need that information. Hand notes also have relevant facts noted more prominently so you don’t need to sift through information. Keep up the interesting reading.
October 12, 2013 at 5:00 pm
You can’t draw pictures in enotes, they will become acronym and dot point notes. A well written nursing note is a narrative of the interaction too.
Paul McNamara says:
February 9, 2014 at 11:17 am
I love drawing pictures in file entries (as per this blog post: ), but also like the idea if direct-entry into eMedicalRecord. Does anyone know if the two can be combined easily?
October 12, 2013 at 4:57 pm
Love your work Ian but I was always under the impression that only blue and black pens were legally allowed to be used in patient case notes? As for electronic medical records – I am finding I am documenting less now that our hospital as transferred from written case notes. I am finding that because the documents available are not the same as a progress notes that I am tending to just write single words when I document vital signs as opposed to a sentence or two giving a better picture of my patient. I work in an ED and I am finding that my initial documentation of presenting complaint, past medical history and medication taken has declined. The current system that we use doesn’t allow for easy documentation of things such as smoking history, NOK aware of presentation as well as simple things such as BGL, weight and orthostatic BP. It has increased our time taken to document but decreased the amount that we document as well as reducing our ability to provide patient care.
Michelle Moseley says:
October 11, 2013 at 8:49 am
Yay! This is what I teach grads. Not only does it have all the advantages that you mention, but also makes the auditing process much easier (unfortunately that usually includes me). Headings, underlining, draw pictures…knock yourselves out!
October 9, 2013 at 8:33 pm
Great article! Communication – such a major issue… I try my best to gather evidence to make it easier for the Doctor to understand – they are so busy/we are so busy …but it’s not my name signature on the script so I always try to help the Doctor who has the liable skills to have the final say.