Check Boxes Are No Substitute for Narrative Documentation

Thank you for Lisa Day’s insightful article, “What Is Documentation for?”¹ Although I too understand the importance of standardized documentation for auditability of regulatory requirements, documentation that consists of only standardized charting fails to demonstrate critical thinking and the true art of nursing. It teaches up-and-coming nurses that the context and relational aspects of nursing practice are not important.

I use narrative format often to express my concerns or document why I chose to act in a certain way, how patients responded to my actions, and if I phoned a physician exactly what I told him or asked of him. Not only does this serve as a communication tool for other nurses and ancillary departments caring for the patient, but I believe it protects me from liability. This sort of documentation can portray critical thinking in a way that standardized check boxes do not. The following is an example...