The five rights of patient medication safety include: the right person, the right drug, the right dose, the right route and the right time. It seems pretty simple enough. The last piece critical to medication safety is the right/write documentation. Not just because of the fact that if it is not documented it is not done, but if it is not documented what is stopping someone from giving the medication again.
I am continually amazed when doing case reviews at the lack of documentation. Besides the obvious legal peril that not documenting may leave someone in, the safety implications are often overlooked. And don’t forget the issue of payment and reimbursement. How can you bill for services that there is no record of? More than once I have I seen charges written off because after reviewing a medical record the “patient’s story” is not clear – there are pieces missing and the care that was provided, however appropriate and safe is brought into question because the proof is not there.
This does not just apply to nurses….physicians, respiratory and physical therapists, social workers, paramedics, and anyone who provides care to patients. A hospital defense attorney’s worse nightmare is to have to defend a hospital or provider using a chart that is missing notes and documentation. Documentation is just as important as performing the five rights.
Connect the dots. Close the loop. Write it down. Take credit for the care or treatment that was provided.
Of course, make sure what is written is both legible and spelled correctly.