Reducing risk through documentation  

Documentation to many people may seem to be a burden, but I have learned how crucial it can be. During my Microbiology lab (BIOL 250) students were given an “unknown” species and was tasked to identify what type of bacterium it was (Artifact1). Proper documentation was imperative to the process of determining the species. Each day a task was performed to determine what the species was. Once the test was finished I documented the results, because the test was only viable for 24 hours. Due to the limited time, I only had one chance to perform each test. If you did not correctly document your results you could conclude false results. This is similar to a clinical setting, in that you need to quickly diagnosis a patient so that you can begin treatment. With the wrong diagnosis the patient would undergo expensive and unnecessary treatment. Therefore, it is important to learn to follow proper protocol and documentation before entering the clinical settings.  

When I first started my job as a nurse tech, we had orientation in which we discussed how to document using their electronic medical records system. My instructor explained to us how going through protocol and documenting could one day save your job. For example, if a patient has high blood pressure, then you must report it to the nurse and then document that you reported it. If you do not document that you told the nurse and the patient experience a Hypertensive, high blood pressure, crisis, then the nurse can say she did not know, and the blame falls onto you. Therefore, it is vital to follow proper protocol, not only to protect yourself, but to also reduce risk for your patient.   

After our first SMART study data collection, I had the task of inputting our data. While going through files I often found information missing or that was abnormal. Due to protocol, we had a notebook in which we would document if there was something that could cause the participants measurements were irregular, such as if they were wearing jeans, or if a mistake was made (Artifact 2). The problem happened when the issue was not documented, which happened often. During the SMART study debriefing, I brought up how everyone should make sure they were documenting in the notebook, even if it the problem does not seem of importance. Importance can be perceived differently for each person. For example, one may not see someone wearing jeans as to be noteworthy, but this can cause a person’s hip circumference to be larger. This is especially essential when we begin to analyze our data from the study. If this person’s hip circumference was large for their other body measurements, we will know it was due to them wearing jeans.  

Protocols are put into place by professionals that have done extensive research to make them. Therefore, they should be trusted and followed. In research it can help determine why there is irregular data. In the health care field, it can reduce the risk of preventable complications for the patient and yourself. Properly documenting, also, allows for information to be effectively passed along a health care team by making sure they receive all information needed. Documentation may seem to be a burdensome task at the time, but the wrong diagnosis and subsequent treatment puts the burden on a vulnerable patient, as well as a liability burden on the licensed health professional and health system. 

 

 

 

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