The following perspectives on documentation come from a nurse navigator who shares why patient experiences are more than words on paper.
When I went to nursing school more than a decade ago, 100% of our documentation was on paper. We were taught to be thorough, honest, and concise. I could write a detailed head-to-toe assessment that addressed every body system and patient safety. Every note started with addressing patient conditions from doorway perspective and ended with call bell within reach, bed in lowest position and locked.
I’ve always loved being a nurse and certainly have had shifts where I left feeling I had given my all. But only since I have been working as a palliative care nurse have I felt that sometimes words are not powerful enough. Words lack power. The nursing notes I once adored and reread with pride now seem to leave me wanting. The words don’t convey the tears that fall nor the prayers that are lifted. More than 30 minutes spent reviewing labs, history, and patient chart do not convey the agony our providers have over the decisions they make. “Patient instructed to call nurse if pain greater than 3/10” does nothing to measure the heaviness of the stories our aides hear as people struggle with their mortality. Orders received and visits scheduled do not express the relief provided daily for countless people and caregivers.
The words are thorough, the words are honest, and the words are concise, but the words are no longer a source of pride. The pride is now in the work. The work holds the honor of sharing in the scary unknown. The work houses the love expressed in processing the fears and grief to get to the peace. The work includes showing grace when the daggers of anger are hurled knowing they have to be thrown. The work’s reward is the restful night’s sleep knowing that all has been left on the field and recharge has to happen because I have the privilege of doing it all again.
--Angela H., nurse navigator