But when documentation is done poorly, you end up losing a lot of time. Time gets lost because Poor handwriting takes time to figure out or necessitates calling the writer to find out what the writer wrote. Obscure abbreviations cause the reader to waste time trying to figure out the meaning. Not charting right after an event makes it harder to remember what needs to be documented, so you spend more time charting later. You also run the risk of failing to document correct or complete information.
People fail to sign out charts from the clinical area.
Often charts are removed from the clinical area for valid reasons. Even if one person knows that the chart was being taken, they may not be available when the chart is needed, valuable time is wasted trying to locate the record. Decisions were made on information in the record, only to find out later that someone had charted an assumption that was incorrect. So in the end you, had to back up and start over. IS Quality Patient Care .