Objective Documentation Considerations
Objectives
* Identify appropriate documentation practices that support patient safety and continuity of care. * Summarize how objective charting and clear communication aids the interdisciplinary team. * Identify charting practices that contribute to reducing legal risk and liability.
Patient Safety and Continuity of Care
Documentation communicates the what, why, and how of clinical care that we deliver. As BHSs and RNs, it's imperative that we document clearly, concisely, objectively, and thoroughly. Poor documentation affects patient care delivery in a number of negative ways (e.g., patient management, care continuity, legal ramifications, quality, and health outcomes). Lack of accuracy and poor quality documentation lead to adverse outcomes, medical errors, and can even contribute to patient mortality. Focus on charting information in an objective manner.
What does charting objectively mean to you?
First let's compare objective vs. subjective documentation. Think facts vs. feelings. Objective documentation- verifiable information based on facts and evidence. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. Subjective documentation- information or perspectives based on feelings, opinions, or emotions. We can use nausea as an example. If a patient tells us that they are feeling nauseous, this is a subjective experience because we cannot confirm that the patient is nauseous. We interpret what we're told.
Supports Treatment Planning and Team Communication
Your documentation matters!
Our documentation tells a story of our patient's entire hospital course. This story should be founded on timely, complete, and accurate data that's continually collected and analyzed. As clinical staff members, our entries help teams to individually plan for care, treatment, services, and the discharge care needs of patients. As we utilize eStar to document care in an electronic medical record (EMR), let's think about the advantages. These are huge, especially in behavioral health, and include: * improved quality, accuracy, and timeliness of patient information, * increased reliability, * improved access, * improved utilization management, * cost containment, and * improved quality of care.
Legal and Regulatory Considerations
We should remember that our documentation satisfies legal and regulatory requirements by a number of agencies.
We've all heard the adage that "If it wasn't documented, it wasn't done." This remains a very true and relative statement. This becomes particularly important when we consider the legal aspects of behavioral health practice. The documentation that we complete helps VUMC to comply with Federal and State laws. Additionally, our documentation may be reviewed or critiqued by regulatory agencies like The Joint Commission, or Centers for Medicare and Medicaid when they visit or audit our hospital. The patient record we create is also a legal document and must be accurate, timely, and thorough. We should objectively chart care in a brief, factual manner that is free of opinion, judgement, or assumption.
+ info
The Epic system has multiple analytics built within, to act as safety mechanisms related to patient safety. Pay attention to warnings and alerts! In a system that has many conveniences as part of the build (e.g., check boxes and drop down menus), let's look at some best practices (regardless of your role), to remember when documenting
Points To Remember Regarding Documentation
- Avoid judgement statements, or expressing opinions.
- Do not chart in bold, "ALL CAPS," or with exclamation points to emphasize or express a point.
- Do not list the name of another patient in an entry. Also, do not list individual staff by name.
- Do not indicate that a Veritas report was completed in the patient record.
- Do complete a Veritas for the following occurrences. Click the radio button for a listing.
- Remember that patients can view notes in real time. Chart objectively, concisely, and factually.
- The following events require a narrative note. The RN or BHS with the most information should enter the note. Some events will require RN specific documentation. Click the radio button for a listing.
- VPH's "Good Catch" nominations can be submitted via Veritas, or by a QR code shared monthly. This is a way to elevate your peers for "catching" errors or near misses that impact patients or staff. Nominees are recognized monthly in the VBH Town Hall meetings.
+ info
And finally, let's look at some role-specific considerations.Click the radio button relative to your role for more information.
RN
BHS
Summary
With regard to documentation best practices:
- Avoid opinions and judgment,
- Use clear, concise language,
- Document all critical events,
- Follow role-specific guidelines, and
- Ensure legal and regulatory compliance.
Resources
Demsash, A. W., Kassie, S. Y., Dubale, A. T., Chereka, A. A., Ngusie, H. S., Hunde, M. K., Emanu, M. D., Shibabaw, A. A., & Walle, A. D. (2023). Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ Health & Care Informatics, 30(1), 1–7. https://doi.org/10.1136/bmjhci-2022-100699 Uslu, A., & Stausberg, J. (2021). Value of the electronic medical record for hospital care: Update from the literature. Journal of Medical Internet Research, 23(12). https://doi.org/10.2196/26323 Warnings Designed with Patient Safety in Mind | Epic. (2019, May 2). Www.epic.com. https://www.epic.com/epic/post/warnings-designed-patient-safety-mind/
Thank You!
- Patient falls
- Patient injuries
- Self-injurious behaviors
- Elopement
- Reports of abuse
- Patient death
- Patient/family complaints
- Medical event/Code Blue
- Medication errors
- Aggression/assault towards others
- Sexual events
- Any other unexpected/adverse events
Work with your nurse to photograph and submit pictures of wounds using the Haiku app. Enter significant event notes as necessary for narrative-type informational notes to share with the team. Document groups facilitated during your shift and include attendance, participation, and any other relevant information regarding patients and information sharing.
Photograph and submit pictures of wounds/pressure ulcers using the Haiku app. Enter a note that the provider was made aware of the wound. Document when advised to NOT begin a detox order set (i.e., the provider recommends to delay beginning a CIWA). Complete a Veritas and event note for a transfer of a patient to the ED. Complete a Veritas and event note after a patient fall. Especially on Adult 2 and 3, chart the exceptions. For example, if a patient is given PRN meds for sleep and remains up all night, chart the response in more detail. Another example would include documenting the level of assistance needed with ADLs, participation level, and related abilities.
- Patient falls
- Patient injuries
- Reports of abuse
- Patient death
- Patient/family complaints
- Medication errors
- Elopement
- Aggression/assault towards others
- Self-injurious behaviors
- Sexual events
- Medical event/Code Blue
- Unexpected adverse events
- Equipment failures/broken equipment
- Process issues
- Staff injuries
- Good catches
Objective Documentation Considerations
Lesley W-H
Created on October 17, 2025
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Transcript
Objective Documentation Considerations
Objectives
* Identify appropriate documentation practices that support patient safety and continuity of care. * Summarize how objective charting and clear communication aids the interdisciplinary team. * Identify charting practices that contribute to reducing legal risk and liability.
Patient Safety and Continuity of Care
Documentation communicates the what, why, and how of clinical care that we deliver. As BHSs and RNs, it's imperative that we document clearly, concisely, objectively, and thoroughly. Poor documentation affects patient care delivery in a number of negative ways (e.g., patient management, care continuity, legal ramifications, quality, and health outcomes). Lack of accuracy and poor quality documentation lead to adverse outcomes, medical errors, and can even contribute to patient mortality. Focus on charting information in an objective manner.
What does charting objectively mean to you?
First let's compare objective vs. subjective documentation. Think facts vs. feelings. Objective documentation- verifiable information based on facts and evidence. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. Subjective documentation- information or perspectives based on feelings, opinions, or emotions. We can use nausea as an example. If a patient tells us that they are feeling nauseous, this is a subjective experience because we cannot confirm that the patient is nauseous. We interpret what we're told.
Supports Treatment Planning and Team Communication
Your documentation matters!
Our documentation tells a story of our patient's entire hospital course. This story should be founded on timely, complete, and accurate data that's continually collected and analyzed. As clinical staff members, our entries help teams to individually plan for care, treatment, services, and the discharge care needs of patients. As we utilize eStar to document care in an electronic medical record (EMR), let's think about the advantages. These are huge, especially in behavioral health, and include: * improved quality, accuracy, and timeliness of patient information, * increased reliability, * improved access, * improved utilization management, * cost containment, and * improved quality of care.
Legal and Regulatory Considerations
We should remember that our documentation satisfies legal and regulatory requirements by a number of agencies.
We've all heard the adage that "If it wasn't documented, it wasn't done." This remains a very true and relative statement. This becomes particularly important when we consider the legal aspects of behavioral health practice. The documentation that we complete helps VUMC to comply with Federal and State laws. Additionally, our documentation may be reviewed or critiqued by regulatory agencies like The Joint Commission, or Centers for Medicare and Medicaid when they visit or audit our hospital. The patient record we create is also a legal document and must be accurate, timely, and thorough. We should objectively chart care in a brief, factual manner that is free of opinion, judgement, or assumption.
+ info
The Epic system has multiple analytics built within, to act as safety mechanisms related to patient safety. Pay attention to warnings and alerts! In a system that has many conveniences as part of the build (e.g., check boxes and drop down menus), let's look at some best practices (regardless of your role), to remember when documenting
Points To Remember Regarding Documentation
+ info
And finally, let's look at some role-specific considerations.Click the radio button relative to your role for more information.
RN
BHS
Summary
With regard to documentation best practices:
Resources
Demsash, A. W., Kassie, S. Y., Dubale, A. T., Chereka, A. A., Ngusie, H. S., Hunde, M. K., Emanu, M. D., Shibabaw, A. A., & Walle, A. D. (2023). Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ Health & Care Informatics, 30(1), 1–7. https://doi.org/10.1136/bmjhci-2022-100699 Uslu, A., & Stausberg, J. (2021). Value of the electronic medical record for hospital care: Update from the literature. Journal of Medical Internet Research, 23(12). https://doi.org/10.2196/26323 Warnings Designed with Patient Safety in Mind | Epic. (2019, May 2). Www.epic.com. https://www.epic.com/epic/post/warnings-designed-patient-safety-mind/
Thank You!
Work with your nurse to photograph and submit pictures of wounds using the Haiku app. Enter significant event notes as necessary for narrative-type informational notes to share with the team. Document groups facilitated during your shift and include attendance, participation, and any other relevant information regarding patients and information sharing.
Photograph and submit pictures of wounds/pressure ulcers using the Haiku app. Enter a note that the provider was made aware of the wound. Document when advised to NOT begin a detox order set (i.e., the provider recommends to delay beginning a CIWA). Complete a Veritas and event note for a transfer of a patient to the ED. Complete a Veritas and event note after a patient fall. Especially on Adult 2 and 3, chart the exceptions. For example, if a patient is given PRN meds for sleep and remains up all night, chart the response in more detail. Another example would include documenting the level of assistance needed with ADLs, participation level, and related abilities.