Can We Talk?: Has Anyone Seen My Data?

  I have been teaching undergraduate research and supervising student nurses in clinical settings for more years than I care to think about – years in which advancing technology has changed practice. To facilitate more accurate record-keeping (and in keeping with increasing regulatory oversight), we have evolved from paper charting to computer programs. However, the quality of what we chart has not improved. This is discouraging, particularly to this professor. I have spent many hours and much effort lecturing students on the why’s and how to’s of assessment and corresponding documentation, only to discover that examples in practice are difficult to come by.   This past year, I enlisted several undergraduate nursing students in my research, allowing them to perform some basic data collection. The students review patient charts for specific data I need regarding the patient’s condition on admission and extract entries from the weekly nurse’s notes relevant to the patient’s skin condition. Some facilities do a decent job of entering information into the patient’s record but generally the students are appalled at the lack of skin condition documentation. Students approach me in defeat, visibly upset they can’t find information on the patient’s skin and convinced their skills are at fault. I look through the charts with them and point out that their lack of experience is not to blame– rather, the skin documentation is not available.   Several students also have noted the “moving” pressure ulcer phenomena– ie, the ulcer that changes stage, size, and location depending on which staff member entered the information on the chart. Other students are amazed that a “reddened area” is documented on admission but nothing further is written. Equally puzzling is how nurses can perform a pressure ulcer risk assessment on a person with an existing wound and still rate him/her as low-to-moderate risk. Persons who already have a pressure ulcer must have been at risk at some point and now are at high risk for other wounds developing. But from the staff perspective, the facility-required paperwork is complete if the ulcer is “documented.” Whether results and observations applied to the person are logical is seemingly inconsequential.   The teacher in me wants to keep stressing the necessity of documentation (although I must be doing it in a foreign language that no student recognizes). The clinician in me wants to run up and down the medical center hallways shouting, “The surveyors are coming. The surveyors are coming! Document, document, document!” I doubt if either approach will improve the charting.   We stress critical thinking in our education programs but our efforts do not seem to translate to documentation skill. Perhaps the current trend in instruction – ie, tying evidence to practice – will help. I certainly hope so. I am not getting any younger and will eventually become one of the patients whose assessment will go unrecorded. This article was not subject to the Ostomy Wound Management peer-review process.