The 5 “W’s” of Documentation
Stephanie Rothery, AINS, ARM - McNeil & Co. Risk Management Supervisor
December 17, 2024
Imagine sitting in court and having a judge ask you if you have proof that you completed an installation job correctly. You hesitate, look around at everyone in the room staring at you and you say, “well no mam, I don’t have any proof”. Are they going to just take your word for it? Documenting activities we do is not always on the top of our priority lists, but when you are being questioned by a judge in front of others, you may wish it had been at the time. Whenever we are completing a job, collecting information, or reviewing something, it is important to document as much as possible with as much detail as possible to help protect ourselves from future liability.
There are 5 key elements of documentation: what, when, where, who, and why?
- “WHAT” do we document?
We should document any work that is being conducted, incidents that occur or processes that take place. Using a checklist or step-by-step guide can help us ensure details aren’t missed.
Some examples of WHAT we should document:
- Installation of equipment
- Inspections or cleaning processes
- Emergency assist calls
- Complaints/Allegations
- Employee records (promotions, disciplinary, achievements, etc.)
- Service contracts
- Incident reports (injuries, car accidents, disputes, etc.)
- “WHEN” do we document?
The best answer to this question is as much as possible. Document before work is conducted, during the work, and after the work is completed. Documentation should be made after any kind of incident has occurred, immediately following a complaint, after a discussion may have been held or when acting against someone.
Some examples of WHEN to document:
- If we are in a car accident, the police come and document everything that occurred. The same goes for a job site— if you complete a task, document it showing who did the work, when it was done and that it was left in working order.
- An employee brings up anyone (not only a supervisor) that they feel like they are being harassed. Document this immediately and with as much detail as possible (date, time, details, etc.).
- “WHERE” do we document?
Depending on an organization’s policy, documentation can be done electronically or on paper. If documentation is made on paper and there are several parties involved, 3-way copy paper would
allow a copy to be saved by each entity involved. Sometimes we may need to add documentation to a specific employee or team’s file. Certain documentation may also need to be made online or with an authority having jurisdiction.
Some examples of WHERE to document:
- In a logbook
- A job tracker
- Electronic record software
- Online document storage
- In a notebook (secured if needed)
- “WHO” should document?
Everyone possible (to an extent) should document, but having a designated person may help avoid discrepancies between various documentation efforts. While we may not need everyone transcribing every event that occurs during their day, there are the specific incidents or occurrences we talked about above that should be written down by either the parties involved or a designated contact with an organization.
Some examples of WHO should document:
- Someone involved in an incident where injury or damage of property occurred
- Service technicians
- Equipment installers
- Supervisors/Managers
- Officers/Shift Leaders
- Attorneys
- Notaries
- “WHY” do we document?
We document to protect ourselves or our organization. Documentation may take time, but it could save thousands of dollars in legal fees or investigations in the future. Documentation allows us to fall back on what truly occurred and not rely on memory or hearsay. Documentation also helps us to potentially gain insights or identify patterns that need to be addressed.
Some examples of WHY we document:
- To be prepared for a legal hearing
- To prove innocence
- To remember
How do we ensure we are documenting appropriately?
When documenting, it is important to establish a quality assurance process for your organization’s regular documenting purposes. Documentation should be consistent and concise. A process should be established to review regular documentation that is made by employees to ensure they are avoiding discrepancies. Remember, this documentation is to protect you and your organization and could be brought up later in court— sometimes several years later. Be sure to utilize resources around you to assist with this quality assurance such as legal attorneys, insurance companies and state entities.
How long do we keep documentation and how do we dispose of it?
Some documents must be retained for certain time periods depending on the type of document. The document may also need to be kept in certain formats or locations. Be sure to check with your state or local jurisdiction for any record retention or disposal requirements as some documents may require special disposal when the time comes.
Let’s go back to that image of you in court, sitting in front of that judge. They ask you for proof that you installed something correctly for work. You reply with a confident “Yes!” reach down and pull out a copy of the checklist you used while you were installing along with the photographs of before, during and after the installation that shows it done correctly. The judge thanks you for your time and dismisses the case. What could have been a long-drawn-out investigation with a potential large expense luckily turned into a 30-minute trip to court and continuation on with life. Documentation could make or break you or your organization’s future. Take a few minutes of time and write it down; you may be grateful you did.