Documentation. If you haven't written it, you haven't done it

Public health nurses reminisce about the days when writing about the care given was a small part of the workday. Third parties certainly were not as interested in what was documented then as they are today. Perhaps the state would admonish an agency about the fact that goals were missing in the charts, but no one talked about documentation being the key to reimbursement and agency survival. Needless to say, times have changed. Public health nurses are suffering these days because they are not only laboring to provide care to a group of patients who are older and sicker than they were in the past, but they are spending more hours each day writing about what they have seen and done. These nurses are haunted by the fear that they might omit a vital piece of information which would jeopardize both their licenses and reimbursement. New forms initiated by the federal government to improve screening for nonreimbursable care have been successful. They have helped to increase denials as well as the volume of paperwork necessary for writing up a Medicare case. Consequently, nurses are frustrated. Although they are writing more, the outcome is negative. Documentation is an essential part of care. It is a vehicle for communicating from one professional to another about the status and needs of the patient. In fact, the chart is often the only means to demonstrate that professional standards, state regulations, and the criteria for reimbursement were met. However, to the extent that charting significantly interferes with the amount of time nurses can spend with patients, it must be limited.(ABSTRACT TRUNCATED AT 250 WORDS)