As a nurse, this phrase holds the same meaning regardless of the clinical area where you may be providing direct care. The phrase is reflecting on the role of nursing documentation in nursing care delivery.

I am one of the nurses who began my nursing career using paper based charts and documentation records. Little time was spent on learning how to chart on the paper flowsheets, medication administration record (MAR) and nursing notes. The same is true of getting and giving report.

I learned from my preceptor during my first Registered Nurse (RN) role as a new graduate nurse. As a travel nurse, the orientation time was at most a day or two with another nurse. Thus, little focus was placed on how to document on the paper record for the patient.

Many of the nurses working today began their career on electronic nursing documentation. The choices of what one can document far exceeds what was visible on a paper based flowsheet. For a new graduate nurse, differentiating between all of the different fields and deciding which must be completed and/or which are not necessary for that patient is not easy to decipher when there is an underlying thought of:

“If it is not documented, it is not done.”

In Episode 8 of KnowMyVoice®, I discuss the context behind this phrase. I also explore how we may begin to shift away from something that feels like a “have to do” toward something that resembles a way to communicate through a digital form for the benefit of the patient.

Nursing documentation is a requirement but it is a requirement because of what the documentation provides to deliver the care patients need to make the best informed decisions as well as monitor progress and intervene as necessary.

Take a listen when time permits. Subscribe to the podcast and stay tuned for the next episode.