Camp professionals generate many documents. While some documents aren’t retained very long, others are preserved because they contain critical information. It’s these critical records that deserve attention; do they contain sufficient information presented in an appropriate manner? In other words, how does one “write right”?
Interestingly, literature from the camp community is thick with information about what incidents to document (Coleman and Coleman, 2009; Coutellier, 2008; Ball and Ball, 2009) but light on comment about the characteristics of good documentation. That information tends to come from risk management literature and is the subject of this column. General guidelines will be presented. Individual camp professionals are reminded to consult their legal expert regarding the application of this information to their camp.
General Documentation Guidelines
Appropriate documentation is more than just “filling in the blanks” of an incident report or health record. According to various sources (Harper College, 2013; Hendren, 2011; Richards-Gustafson, 2013; Treder, 2013), these broad practices are standard:
A. Document in a timely manner (as soon as possible after the event) using the appropriate form or per the direction of the individual who oversees the documentation process.
B. If writing the information by hand, use a pen with black or dark blue ink — and write so others can read what has been written! If using a keyboard, initial each page by hand and then place one’s full signature at the end of the document.
C. Use the legal name of individuals. Insert date(s) and time(s) as relevant to what is being written. Consider adding camp session for campers or job title for staff.
D. Describe the context/setting: When and where did this happen? List factors that may be unique to the environment. Describe any prior interactions experienced with the individual(s).
E. Objectively describe what happened in chronological order; stick to the facts. Record details in objective terms. Describe what was seen and heard by the person doing the documentation; distinguish between personal knowledge and what one learned from others (e.g., “Sally told me that . . .”). Include behavior (actions) and what was said (use quotes); describe tone of voice and observed body language. Include how often something happened (frequency) and how long it lasted (duration).
F. Be accurate, concise, and clear. Double-check names, spellings, dates, and times. Be grammatically correct and use appropriate punctuation. Skimping on these elements risks being misunderstood or introducing doubt as to what was meant.
G. Name others who were involved as witnesses (those who actually saw what happened) and/or to whom the incident was reported.
H. AVOID opinions and blame statements.
I. Date and sign (do not merely type) the documented content when it’s completed.
Note Underlying Assumptions
Reading the information just described may trigger other questions, especially regarding the assumptions upon which documentation practices are based. For example, most camp staff are emerging professionals who do not routinely document incidents. As a result, assume that they will need coaching about how to document. Provide that coaching during orientation but also at the time of an incident. Taking a moment to review the guidelines before someone — camper or staff member — documents the incident from his or her perspective should help create a better document.
Also consider how long documentation might be kept. This decision not only affects where one might store critical records, but also colors the decision as to what medium is used for critical documentation. Paper remains just about the only surefire archive option in today’s world. Computer systems and devices have changed so quickly that it’s difficult to tell if today’s option will be retrievable in tomorrow’s world.
Another underlying assumption is that documentation reflects the perception of the writer. An eighteen-year-old, brand-new camp counselor would be held to a different expectation than an experienced camp professional. There is allowance for recognizing that documentation expectation varies given individual experience and age.
Documentation Done by Health Center Staff
It’s easy to forget that health center staff document many interactions with campers and staff. Indeed, some camps fail to orient their health center staff to the camp’s expectations surrounding documentation. Just as one thinks through documentation guidelines for incidents that occur outside the health center so, too, should one consider what guides documentation done by health center staff.
In general, documentation done by health center staff should (a) accurately reflect the client-provider interaction in a timely manner; (b) be appropriate to the healthcare provider’s scope of practice; (c) comply with legal and professional practice standards for healthcare documentation; and (d) serve to protect both the camp and the provider. The sidebar below contains a sample documentation policy for nurses who staff a camp health center.
The professional staff working in the health center will know their profession’s documentation standards. What they need from their camp supervisor is a conversation about how that plays out in the camp setting. When and how the camp log is used should be explained. When and how to document care given to a camper or staff member needs explaining. How and where one records phone conversations with parents or external consultants (e.g., the camper’s MD, a pharmacist, a mental health professional) should be discussed. The scope of computer-based record keeping needs explanation along with instruction that each health center staff member uses his or her own username/password to assure tracking (e.g., who entered what data when on that computer-based record).
If not instructed, these same healthcare professionals may approach documentation with an “it’s just camp” attitude, and their documentation may not comply with the standard of practice for their profession. They have been known to provide too little information, which becomes especially problematic should an incident occur. For example, writing “headache; two Tylenol” on a client record does not describe assessment nor evaluation; consequently, it is not sufficient documentation for nurses. How much better to read: “Client headache related to sun glare from guarding without polarized sunglasses; provided 650 mg Tylenol with 8 oz water with instruction to use appropriate sunglasses and return in one hour if headache not improved.”
Yes, it takes time to appropriately document. Allowance for this time must be acknowledged and provided by supervisors, even if that supervisor is not a healthcare professional. Making sure there’s adequate time to document can be tricky when the health center is particularly busy, such as the time just before bed or when an outbreak occurs. Supervisors can help health center staff identify strategies to address this challenge. Something as simple as making a brief note in a log and then returning to more thoroughly document on the client health record a bit later might be all it takes.
Train Staff
Because staff provide documentation, explain the camp policies surrounding appropriate documentation practices. This might include not discussing information with others unless the camp’s administration or attorney is present. It may include the policy of documenting within a specific timeframe to preserve memory, as well as a reminder that documentation may be read by people beyond the director.
Be sure staff understand who receives their documentation and who they can consult should questions arise during the process of documenting. Also make clear just who “owns” the documentation. May a parent, for example, be given a copy and, if so, under what conditions?
Because some staff are supervisors, consider talking with them about the elements to include when documenting employee actions associated with termination. These elements are often colored by state regulations, another area where legal consult is valuable.
“Writing right” is a skill that’s vital to today’s camp professionals. In view of the upcoming busy summer season, now is the time to review and update your camp’s documentation guidelines. Then consider staging an incident during staff orientation and having each staff member document what they observed. Compare and contrast those written descriptions. What more might you and your staff learn?
Sample Health Center Staff Documentation PolicyNURSING documentation addresses these elements. Some nurses may prefer to use the acronym SOAPIE (subjective, objective, assessment, plan, implement, evaluation) to guide their charting process. At minimum, the expectation is that each element is addressed when charting.
WILDERNESS FIRST AID (WFA) credentialed staff document to the following standards:
PROVIDERS WITH OTHER CREDENTIALS document in a manner that (a) reflects the practice of that discipline and (b) is appropriate to the provider’s scope of practice. Minimal expectation is as described for the WFA credential. Optimal documentation reflects what is expected of nurses. |
References
Ball, A. and Ball, B. (2009). Basic camp management: An introduction to camp administration. Monterey, CA: Healthy Learning.
Coleman, M., and Coleman, J. (2009). Crisis communication: Weathering the storm. Monterey, CA: Healthy Learning.
Coutellier, C (2008). Risk and crisis management planning. Monterey, CA: Healthy Learning.
Hendren, R. (2011). Best practices in filling out incident reports. The Leaders’ Lounge. Retrieved from http://blogs.hcpro.com/nursemanagers/2011/08/best-practices-forfilling-out-incident-reports.php
Harper College Staff (2013). Tips for documenting incidents. Harper College. Retrieved from http://goforward.harpercollege.edu/about/offices/conduct/resources/tips.php
Richards-Gustafson, F. (2013). What elements must be included in documenting an employee for termination? Demand Media. Retrieved from http://smallbusiness.chron.com/elements-must-included-documenting-employee-termination
Treder, E. (2013). How to document any incident. CPI Training. Retrieved from http://ezinearticles.com/?How-to-document-Any-Incident&id=6060437
Linda Ebner Erceg, RN, MS, PHN, is the associate director of Health & Risk Management for Concordia Language Villages and executive director of the Association of Camp Nurses in Bemidji, Minnesota.
Originally published in the March/April 2014 Camping Magazine.