1-800-267-3390Question:
My unit is always short-staffed, meaning that we have to constantly triage orders and reassess patient needs. Should this be documented in the patient’s chart?
Answer:
Across Canadian provinces and territories, health care organizations are experiencing unprecedented nursing shortages, which have been further exacerbated by the COVID-19 pandemic.1 The Canadian Nurses Association has identified the shortage of health care workers, specifically nurses as the most severe and urgent challenge for the Canadian health care system.2
Excessive workloads, understaffing, and overtime requirements are systemic issues stemming from nursing shortages, which should be carefully documented and reported to management. The purpose of documenting systemic issues and their impact is to alert those who are in a position to act. Nurses should use appropriate channels, outlined by their employer’s policies and procedures, such as incident reports, professional concern forms, emails to management or union representatives, etc., to report any systemic issues affecting their nursing practice.
By contrast, the primary purpose of the patient chart is to document all important events in the care provided to the patient, including relevant communications within the healthcare team related to the patient. Nurses are required by law and their regulators’ practice standards on documentation to accurately document the specific care they provided to the patient.
Documenting the care provided to patients should remain as accurate as possible, even when it has been impacted by staffing shortages. Consider the following case scenario:
Three of the five nurses on the unit have called in sick for night shift. Orders are written for routine bloodwork for a patient every two hours, with the last bloodwork at 1900h. Due to being understaffed, nurse X was only able to do the bloodwork every four hours. In the chart, she documents
2300h – Blood drawn for routine labs
In this case, the nurse is meeting their documentation obligations by charting patient-specific interventions. Information that may have impaired their ability to perform the bloodwork every two hours could be documented in an incident report or professional concern form or in an email to their manager, as contemplated in the facility’s policies.
Now, consider how the documentation might change if the nurse escalated this concern to the physician in advance, and steps were taken to change the order. For example:
Orders are written for repeat bloodwork for a patient every two hours. When receiving handover at the beginning of their shift, Nurse X expects that they will not be able to do the bloodwork every two hours because the unit is short three of the five nurses scheduled. Nurse X reviews the results from the last bloodwork, which occurred at 1900h, and contacts the attending physician to discuss the situation and ask whether bloodwork can be done every four hours. The physician reviews the most recent labs with the Nurse X and changes the order for specified bloodwork every 4 hours. Nurse X documents:
1935h – Called MD as results from 1900 labs available, reviewed results with MD. New order for bloodwork q4h.
2300h – Blood drawn and sent for routine labs
CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.
- Canadian Nurses Association, “Canada must address its domestic nursing shortage and become self-sufficient rather than deplete other countries’ health human resources, CNA says” (July 3, 2023) online: https://www.cna-aiic.ca/en/blogs/cn-content/2023/07/03/canada-must-address-its-domestic-nursing-shortage.
- Ibid.
November 2024
THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.