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The Devil’s in the Details: The Three Cs of Department Documentation

“We always run the TOSI tests in the morning.”

“We verify that the sterilizer met the correct parameters before releasing the load.”

“We do an annual competency check on all of our technicians in the department.”

Is that so? And how would you prove that in a court of law? Or how would you convince an inquisitive administrator or accreditation surveyor these things actually happened? 

That’s right, I’m talking about the big D, and I don’t mean Dallas. 

Compliant documentation is the key to proving that anything patient-traceable has ever happened in your sterile processing department. That is precisely why everyone from CMS to the C-suite insists it happens during this critical link in the continuum of patient care. Even though we work primarily with water and stainless steel, we prove the quality of our work with pen and paper (or sometimes with flatbed scanners and Wi-Fi).

Even with all this emphasis placed upon the importance of documentation in a sterile processing department, some teams still struggle with getting their documentation right: Complete, Consistent, and Compliant. This article outlines why these three Cs are important to processing quality and highlight ideas for department leaders to make it easy for your technicians to do the right thing when it comes to logging their processing excellence. 

No field left behind: Complete documentation 

One of the most common errors for sterile processing documentation is simply incompleteness. Perhaps someone forgot to initial here or date there. Maybe 20 peel packs were scanned into a sterilization load, but there were actually 25 that were sterilized. “We have the other 19 days logged, what’s the big deal about missing yesterday?”

There are two things to consider here. First, documentation is the record you have of work that has been completed for particular equipment or instrumentation, be it test cycles, actual processing, or environmental controls (such as temperature and humidity). If there is no record for a particular time and date, there is no proof that the required steps in processing actually happened. If a logbook says a laparoscopic grasper had its insulation successfully tested on 2/17 at 2 p.m., but no employee initials are present, there’s no proof that the technician who completed the testing was competent to do so, and so forth.

Second, incomplete documentation signals the potential for serious quality defects in the actual processing of instrumentation. If technicians are not taking the time to sign a receipt or log test results, it begs the question whether they are even taking the time to do the very steps they are failing to document. 


The same yesterday, today, and tomorrow: Consistent documentation

Closely linked to complete documentation is the need for these records to be consistent over time. Your TOSI test logs, for instance, shouldn’t be completed differently depending on the staff member or the day of the week. If the department policy is to retain the completed test strips and affix to the documentation log, this practice should be followed for every test, every time. Deviation from documentation norms are the root of much confusion among various team members responsible for picking up where previous staff left off. 

This particular aspect of documentation also runs up against a common misconception among sterile processing technicians that as long as you are documenting more than your peers, it’s acceptable to deviate from the status quo (e.g., “I like to circle my parameters on the receipt” or “I like to staple my indicator to the envelope”). While the desire to go the extra mile on department documentation is honorable, it opens the door for unnecessary complexity, confusion, and potential liability for attorneys looking to show a divergence of the standard of care from one patient to another. There is no room for personality or creativity in the world of legal documents in which we live. Save that for the SPD poetry slam after work.  


Not just done, but done right: Compliant documentation

This third feature of documentation focuses on whether you are being complete and consistent about the right things. In other words, are you testing what you need to be testing, when and how you need to be testing it? And when you complete your logs, are the parameters and results that are documented actually within the proper ranges for the tests or equipment being monitored. For instance, simply documenting a steam sterilization load at 269° Fahrenheit for 5 minutes is not quite what your accreditation surveyor wants to see, nor what the manufacturer had in mind. If those are the parameters that ran, then that is what should be entered into the log, but then there should also be a record of next steps or corrective actions that were taken to ensure those items did not continue downstream to the patient. 

Compliant documentation requires targeted research beforehand to ensure the specific recommendations and regulations required are being followed in each and every log sheet, and any variation being tracked. There is an aspect of critical thinking that must occur at this point to compare the data being documented with the objective standard that the technician expects to see. Documentation compliance does not mean all tests passed and there were no issues; it simply means every aspect of success and failure in these particular processes was documented in light of industry or manufacturer recommendations. While you must have complete and consistent documentation to be compliant, if you are consistently completing documentation that is out of spec for particular equipment with no corrective action, then you are not really obtaining compliance; you are simply documenting uncorrected process failures.

Helpful tips

One of the best ways to encourage complete, consistent, and compliant documentation in your department is to create an example log to be stored with or near any documentation binders or sheets in your department. This example log would be completely filled out in the standardized fashion you expect from you team and laminated for easy reference and longevity. The example log would be there to answer any questions during the documentation process and serve as a quality-assurance aid whenever your logs are reviewed. 

In addition to creating the standard model for documentation in an example log, department leaders can also create a documentation competency list for annual review and regular department audits. These documentation competencies can help identify potential deviations from the status quo and ensure training is based upon objective standards and not preceptor preferences. This also provides a great opportunity to communicate the legal and quality-related reasons—or the why—behind the plethora of documentation duties technicians have to take part in on a daily basis.

Ultimately, the old cliché is true: “If it wasn’t documented, it didn’t happen.” But as this article highlights, correct documentation in sterile processing must also be Complete, Consistent, and Compliant for it to really count. We owe it to our patients to ensure we cross every “t” and dot every “i” in this mission to #FightDirty every day. And that is a mission we document with both our passion and our pens. 

Feature articles exclusively for Ultra Clean Systems by Weston “Hank” Balch, BS, MDiv, CRCST, CER, CIS, CHL

Weapon of Mass Microbial Destruction * Professional Clean Freak * Podcast Host * Safety Addict * CS/SPD Consultant


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