There was a qualitative study done on nursing intuition that lives in my brain (Benner, P., & Tanner, C. (1987)).

...and later another study of over 31,159 nurse assessments and their "worry factor" (Romero-Brufau et al).

They analyzed and confirmed the link between nurses' intuition that something was "off" and compared that to clinical courses/outcomes.

It's a fascinating look at how nurse "sense" is built over YEARS of subconscious pattern recognition from thousands of clinical situations.

"Thinking like a nurse" is much, much more than holding clinical information and applying it. It's actually complex neural pathways solidified from extensive exposure.

Here are some of the "pools" of knowledge and experience we draw from that arent quantitative:

-Clinical culture; nurse psychology; nurse/specialty workflow.

-Reading in-between the lines to find clues about where to look next

-Recognizing a nuanced clinical language when something is "off"

Even just skimming a chart we get a "feel" for what that black and white 3,000 page document actually looked like in real life.

AI will help. But AI is not ready to replace any time soon.

Sources:

-Benner, P., & Tanner, C. (1987). Clinical Judgment: How Expert Nurses Use Intuition. The American Journal of Nursing, 87(1), 23–31. https://doi.org/10.2307/3470396

-Romero-Brufau S, Gaines K, Nicolas CT, Johnson MG, Hickman J, Huddleston JM. The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. JAMIA Open. 2019 Aug 28;2(4):465-470. doi: 10.1093/jamiaopen/ooz033. PMID: 32025643; PMCID: PMC6994008.)

Documented ≠ Done. Undocumented ≠ Undone.

Documentation is generally considered evidence of care.

But what happens when care was documented but wasn't performed?

On the flip side, what happens when appropriate care was performed-but never documented?

What are some clues?

1. Suspiciously identical/perfect documentation (e.g. patient was turned at 2000, 2200, 0000, 0200, 0400 and 0600)

2. the assessment/documentation doesn't evolve with the patient (especially if the clinician had multiple shifts with the same patient (copy/paste features are still available in most EMR systems)

3. Narrative fields and structured (or flowsheets) do not align. (e.g. "Alert and oriented x4" but patient is on sedation or is delerious)

4. The eMAR shows a different time scanned vs given (e.g. scanner time clocked 1312 but administration time says 0900

5. Other disciplines inadvertently contradict documentation (e.g. Nursing assistant documents safety check at 1200 but patient was off the floor for a swallow study from 1138-1257)

6. Documentation density suddenly changes (i.e. a patient with nothing other than an assessment charted from 0852 suddenly has meticulous documentation immediately preceding their rapid response at 1629)

7. New stat orders without accompanying reassessment or nursing note.

We could go on and ON

What are some other clues you often see?

I'm curious!

#LegalNurseConsulting #MedicalMalpractice #NursingDocumentation #LNC #documentationerrors

Documentation is generally considered evidence of care...

But what happens when nurses document care that was not performed?

On the flip side, what happens when care is completed- but not documented.

*Research has repeatedly associated lower RN staffing and higher workload with increased missed nursing care and adverse patient-safety outcomes.

Unfortunately some of the hardest-working nurses I've known have had very poor documentation habits.

Nurses are the most adaptable group of people I have ever met. We figure out ways to get the essentials charted.

The system is not set up ideal care OR documentation a short staffed shift makes the nurse frequently choose between:

A.) Answering a bed alarm

B.) Administering pain medication

C.) Cleaning up an incontinent patient

D.) Assessing a deteriorating patient

E.) Documenting something you did 10 minutes ago

Want me to share some of the tips and tricks we used in the hospital to determine if care was done vs charted?

I'm curious!

*Gong, F., Mei, Y., Wu, M., & Tang, C. (2025). Global reasons for missed nursing care: a systematic review and meta-analysis. International nursing review, 72(1), e13096. https://doi.org/10.1111/inr.13096

A 2,000-page medical record doesn't necessarily contain 2,000 pages of equally important information.

Just being "detail-oriented" isn't good enough when you need ONLY the pertinent details to the case.

Sometimes the case turns on:

• one abnormal vital-sign trend

• a medication given-or not given

• a change in condition

• an unanswered notification

• conflicting documentation

• an order that doesn't match what happened

• or something that simply isn't there

I can find errors in ANY medical chart you give me (I say this with confidence, because I haven't found a perfect medical chart yet). But charting errors alone do not make a case. Every discrepancy does not deserve equal attention.

Having compounded knowledge and experience allows us to determine if an error is actually a factor in injury (and it's not always obvious!).

What is something you have valued (or wished was different) in work products you've received?

A Washington trial court recently ruled that a physician's underlying ambient-AI recording was an administrative tool rather than part of the healthcare record the patient was entitled to receive.

The final physician-edited note was treated differently from the underlying AI recording.

As ambient AI documentation becomes commonplace, I suspect we're going to be asking much more often:

So what exactly constitutes the medical record? 

Read the article here:  https://wsma.org/membership-memo/washington-court-rules-ambient-ai-recordings-are-exempt-from-patient-record-disclosure/