Nursing Documentation

Your License may depend on it!

Nelia B. Perez RN, MSN PCU - MJCN

Taking a Poll
1. Have you been involved in a patient complaint against your institution? 2. Do you feel like your documentation would support you in a court of law?

A patient you cared for 9 months ago is unhappy with the outcome and has filed a malpractice lawsuit against you. Now what?

The Court

Legal Case Studies

Duty of Care
Based on existence of the nurse-patient relationship A legal status created when the nurse is legally obligated to provide nursing care to a patient Law will demand that the nurse perform as a reasonably prudent nurse

Breach of Duty
Nurses care fell below the acceptable Standard of Care Results: malpractice case compensatory $$$ loss of nurses license loss of job / ability to work

Nursing Negligence / Malpractice

Any action by a nurse that falls below generally accepted standards of nursing care, and causes injury to a patient Even if nurses actions were only contributing cause to the injury

Proximate Cause
PROOF Requires that there be a reasonably close connection between the nurses conduct and the resultant injury

Foreseeability
Nurse has a responsibility to foresee harm before it occurs and eliminate risks Admission Screens Fall Risk Suicide Risk

Illusion of Negligence

Evidence of the truth as to what really happened is unavailable

Damages
Compensated when: Suffered loss or injury through the act, omission, or negligence of another
Medical costs Loss of earnings Impairment of future earnings Past / future pain & suffering

Objectives
1. Explain the importance of documentation as a health care provider. 2. Identify the legal aspects of nursing documentation. 3. Identify the basic information that is required when documenting. 4. Describe specific issues that require documentation. 5. Discuss documentation concerns regarding faxing of records. 6. Discuss computerized documentation concerns. 7. Discuss documentation Dos and Donts.

Objectives
8. Identify how the nursing process impacts nursing documentation. 9. State characteristics of reasonable documentation. 10. Explain what constitutes Nursing Malpractice related to the role of documentation. 11. Identify common charting errors. 12. Identify the consequences of poor documentation 13. Discuss the future of documentation standards. 14. Evaluate the medical record documentation issues in selected legal cases.

Questions
What do you want to know?

Who Cares?
Regulations Client / Patient Insurance

"if it's not documented it was not done"

To avoid litigation, health care providers must comply with established standards of care.

Standards of Care
Legislation / Statutes Practice Guidelines

Prudent Nurse

Knowledge Skill Care Diligence

Why Is the Chain of Command Important?

Courts have held that nurses have a duty to question a physicians order if it is not consistent with standard medical practice.

Initiation of the Chain

Nurse
becomes concerned

Physician
unresponsive or insufficiently responsive might not return a page tells the nurse not to call again about the same problem, or informs the nurse he or she will come in later

Examples Clinical Situations

The dose of a medication is excessive or inadequate. IV fluid orders are incomplete or inconsistent. The nurse is concerned about fetal heart rate monitoring in a patient in labor. The postoperative laparoscopic cholecystectomy patient begins having symptoms of an acute abdominal process. The patient has widely divergent intake versus urinary output. The patient is allergic to the medication the physician orders.

Make Documentation Easier

The Dos The Donts

The Dos
Correct Chart Reflect the Nursing Process Write Legibly Permanent Black Ink Complete / Concise / Accurate

Clear / Concise / Accurate

Wrong Way: Communication with patient's family begun today to specify the manner in which his condition is progressing and suggest a probable consequence of that progression.

Clear / Concise / Accurate

Right Way: I contacted Mr. Boons wife at 1415 hours. I explained that his cardiac status was worsening and that he was being prepared for a cardiac catheterization procedure scheduled for 1600 hours.

Dos
Medications
Route Clients response

Precautions / Preventive Measures

Side rails Restraints

Dos
Nursing Procedures
Name of procedure When it was performed Who performed it How it was performed How well the client tolerated it Adverse reactions

Dos
Phone calls Health Care Team visits Dont wait to Chart Client refusals Clients subjective data

Dos
Medication omission Late Entry Not Applicable Charting Frequency
Facility P&P / Standards

Dos
Approved abbreviations & symbols Discharge instructions Commonly misspelled words Look-a-Like / Sound-a-Like

Dos
Continuation Triplicate / Carbonated Copies

The Don'ts
Complaints Opinions Altering the Record

Red Flags
Adding Information Dating the entry
Dates / Times conflict

Inaccurate Information. Destroying records

Dont
Unapproved Abbreviations Shorthand Vague Excuses

Dont
Chart for someone else Chart Opinions Use Negative Language

Dont
Use vague terms Chart ahead Misspelled words Incorrect Grammar

Dont
Chart staffing problems Chart staff conflicts Chart casual conversations

Fraud

Charting care that you haven't performed is considered fraud

When you make a Mistake

White out / Eraser The word Error Correct the Entry Oops Sad Faces

Dont
Leave empty lines / spaces Write in the margins Make reference to incident reports

Dont
Use words that suggest that there is a clients safety risk Violate client confidentially
HIPPA

Common Charting Mistakes

Failing to record pertinent health or drug information Failing to record nursing actions Failing to record that medications have been given Recording on the wrong chart

Common Charting Mistakes

Failing to document a discontinued medication Failing to record drug reactions or changes in the patients condition Transcribing orders improperly or transcribing improper orders Writing illegible or incomplete records

Failing to record pertinent health or drug information

The nurse neglected to record her patients penicillin allergy in the admission notes. Because the intern didnt know the patient was penicillinallergic, he gave the patient a penicillin injection. The patient, who was incoherent and couldnt tell the intern about the allergy, went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the nurse guilty of negligence.

Failing to record nursing actions

The evening nurse notices heavy drainage from the wound. She checks the nurses notes and finds no evidence that the dressing was changed. She considers the amount of drainage normal for a period of several hours. She changes the dressing but, like the day nurse, forgets to chart her action. The night nurse does the same. Is the condition getting more serious? Is the patients life in jeopardy? No one knows because no one realizes that the patients wound is seeping more than it should.

Failing to record that medications have been given

A day nurse gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw the order for heparin--but no indication that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered--then successfully sued the hospital.

Recording on the wrong chart

Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe hypertension; Mrs. C. Moyer, for acute thrombophlebitis. Mrs. C. Moyers doctor ordered 4,000 units of heparin for her. The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyers chart and administered the heparin. Mrs. B. Moyer started bleeding.

Failing to document a discontinued medication

A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer. So he discontinued the medication. But the patients nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin. The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for the nurses negligence and won.

Failing to record drug reactions or changes in the patients condition

A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). His nurse wasnt concerned, though. By evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and early symptoms of shock. He sued his nurse for negligence.

Transcribing orders improperly or transcribing improper orders

A doctor ordered 5 ml of atropine for a patient on the coronary care unit. He meant to order 0.5 ml, but he didnt include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml, although she didnt think it seemed right. She decided the doctor knew best and didnt check the dose before recording it.

Writing illegible or incomplete records

To play it safe: Print Sign your full name and title Dont leave blank spaces, lines, or boxes on charts Dont use unapproved abbreviations Record every nursing action as soon as possible Write enough to convince the reader

METHODS (STYLES) OF CHARTING

NARRATIVE SOAP SOAPIER FOCUS DATA ACTION RESPONSE PIE EXCEPTION CHARTING

NARRATIVE
CHRONOLOGICAL BASELINE CHARTED QSHIFT LENGTHY, TIME-CONSUMING SEPARATE PAGES FOR EACH SOURCE-ORIENTED

SOAP
USED FOR PROBLEM-ORIENTED CHARTS S SUBJECTIVE. WHAT PT TELLS YOU. 0 OBJECTIVE. WHAT YOU OBSERVE, SEE. A ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA. P PLAN. WHAT YOU ARE GOING TO DO. CAN ADD TO BETTER REFLECT NURSING PROCESS I INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED) E EVALUATION. PT RESPONSE TO INTERVENTIONS. R REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL PAIN. S COMPLAINS OF PAIN IN RUQ O IS PALE AND HOLDING RIGHT SIDE A RECURRING ABDOMINAL PAIN P PUT ON NPO AND NOTIFY PHYSICIAN

FOCUS CHARTING
USES NARRATIVE DOCUMENTATION (DAR)
DATA SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)
ACTION NURSING INTERVENTION RESPONSE PT RESPONSE TO INTERVENTION

EXAMPLE OF FOCUS CHARTING

D COMPLAINING OF PAIN AT INCISION SITE ON LEVEL OF #7 A REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.

R (CHARTED AT A LATER DATE.) STATES A DECREASE IN PAIN, FEELS MUCH BETTER.

PIE CHARTING
Similar to SOAP charting Both are problem-oriented PIE comes from the Nursing Process, SOAP comes from a Medical Model. P-Problem I-Intervention E-Evaluation

SAMPLE OF PIE CHARTING

P#1 Risk for Infection r/t IV Therapy site.

IP#1 Checked IV Site periodocally.

EP#1 No sign of redness and swelling on IV site

CHARTING BY EXCEPTION
USES FLOWSHEETS EMPHASIS ON ABNORMAL (WHAT IS ABNORMAL FOR THIS PATIENT. ALTHOUGH IT MAY BE ABNORMAL FOR THE NORMAL PERSON, IF IT IS ABNORMAL FOR YOUR PATIENT ON A CONSISTENT BASIS, IT IS NO LONGER CONSIDERED AN EXCEPTION. ADVANTAGE

COMPUTERIZED CHARTING
PASSWORD. NEVER SHARE. CHANGE FREQUENTLY. LEGIBLE CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED. DATE AND TIME AUTOMATICALLY RECORDED. ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU PROVIDED BY THE FACILITY. TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT ROOMS, CONVENIENT HALLWAY LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS.

KARDEX
QUICK REFERENCE CHANGED AS NEEDED

NOT PART OF PERMANENT RECORD

ABBREVIATIONS
YOU MUST USE YOUR FACILITYS APPROVED ABBREVIATIONS. BE AWARE THAT A LOT OF COMMONLY USED ABBREVIATIONS: EG. TID, BID, QOD, HS ARE NO LONGER ALLOWED AND SHOULD BE CURRENTLY BEING PHASED OUT OF YOUR FACILITY.

CHANGE OF SHIFT REPORT

PERSON TO PERSON BE PREPARED AVOID GOSSIP/SOCIALIZ ATION TAPE RECORDER

INCIDENT REPORTS
OBJECTIVE DO NOT BLAME OR ADMIT LIABILITY WHAT DID YOU DO? DO NOT INCLUDE NAMES/ADDRESSES OF WITNESSES DOCUMENT TIME/NAME OF DOCTOR DO NOT FILE IN CHART DO NOT WRITE INCIDENT REPORT MADE

CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE COPIED ON COPY. DO NOT SCRIBBLE OUT CHARTING. AVOID USING ERROR OR WRONG PATIENT WHEN MAKING CORRECTION. FOLLOW YOUR FACILITIES POLICY. DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.

Lessons Learned
Documentation validates Nursing Care

A high-risk patient requires complete assessment and frequent monitoring.

Defensive Documentation
Documentation The right way!

Chronological Comprehensive Complete Concise Descriptive Factual

Legally aware Legible Relevance Standard abbreviations, symbols, and terms Thorough Timely

Future
National Standards