Collaborating
to Resolve Practice
Problems

Documenting Problems:
Recording Data

Case Study

Recording Data
If there wasn't time to do proper charting, how would we prepare written documentation of the problem? Because we were adamant that something had to be done about the situation, we were committed to finding time to document.

Recording our observations took place during breaks, before work, after work and in a few cases during off hours. It was difficult writing detailed descriptions of events, observations and actions that had taken place during a 12 hour shift. Furthermore, it was even more challenging to identify the CRNBC Standards that had not been met. This analysis required one to think carefully of the standards and then to prepare a full description that included all of the necessary details.

We relied on each other for support in preparing our documentation. It was hard work. We kept saying "write it up, take the time to write it up." The team leader also did what she could to support the process by offering to help where possible.

In the past, we had used an informal approach to recording our observations. We knew this strategy would not work in this case. We knew we had to be sharp and consistent. Therefore we used a simple tool to assist us with documentation (tool #3). It provided a framework for our observations and recordings plus, it provided us with a consistent approach to documenting the problem. Although most registered nurses are skilled observers and attend to the details of a patient's condition, not everyone is a skilled writer. Thus the form enabled everyone to feel confident recording their observations. As far as identifying which CRNBC Standards were not being met, this took a bit more work. We had to use the evidence to back up our analysis; this kept us honest, limiting judgments that were potentially harmful.

  • What did these registered nurses do to record data regularly and systematically?
  • What must be done to maintain confidentiality in documenting problems?
  • How did the tool assist them in their documentation process?
  • What are the challenges (e.g., computer skills) and what can be done to improve documentation processes?