Nursing Documentation

Your License may depend on it!

CE ANNOUNCEMENTS
Participants must attend entire session to get CE Credit. There are no influential financial relationships, planners, and/or presenters. There is no commercial support that has influenced the planning of this educational activity or content. There is no endorsement of any product by NCNA associated with this program. This program does not relate to products governed by the Food and Drug Administration. If, so appropriate and off-label use will be shared.

Taking a Poll
1. Have you been involved in a patient (client) related lawsuit ? 2. Do you have professional liability insurance? 3. 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 Jury

Legal Case Studies

http://www.nso.com/case/com_index.php

What does the jurors see and hear??

http://www.youtube.com/watch?v=97O7Od6F8PM Lawyer types of med. Malpractice
http://www.youtube.com/watch?v=S2qv5J2S3ec&NR=1 Lawyer explains med. Malpractice http://www.youtube.com/watch?v=226MGeCuHAY News Clip ER Death http://www.youtube.com/watch?v=2xQx24v48ME Lawyer good opening statement

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 RNs liability for LPN & CNAs. 9. Identify how the nursing process impacts nursing documentation. 10. State characteristics of reasonable documentation. 11. Explain what constitutes Nursing Malpractice related to the role of documentation. 12. Identify common charting errors. 13. Identify the consequences of poor documentation 14. Discuss the future of documentation standards. 15. Evaluate the medical record documentation issues in selected legal cases.

Questions
What do you want to know?

Who Cares?
State Regulations Federal Regulations Client / Patient Reimbursement

"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
State & Federal Legislation / Statutes Practice Guidelines

North Carolina
Know your states regulations & statues

The Purpose
to clarify the legal scope of practice & accountability

Learn - CEUs

Practice

http://www.ncbon.com/Practice.asp

Prudent Nurse

Knowledge Skill Care Diligence

Liability: Chain of Command

The Nurses Duty to Intervene Initiating the Chain of Command

What Is the Chain of Command?

Specific course of action involving administrative and clinical lines of authority
Established to ensure effective conflict resolution

Chain of Command?
Clear Understanding Established Philosophy Procedure & Policy

Nurses responsibility to recognize problems with patient care and take appropriate action to prevent patient injury.

Albemarles Philosophy

Albemarles Chain

Why Is the Chain 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.

Documenting This Process Chain of Command

Record events and observations in the patients medical record in an objective and clear manner. Document the specific facts, and carefully record the time of each entry as accurately as possible. Avoid finger pointing and personal attacks on the physician.

Policy & Procedure

Well known by all Improves the quality of care Improves patient outcomes

Negligence?

Practice guidelines Facility policies/procedures

http://ahweb/intranet/Policies/Nursing%20Policies/Nursing%20Standards.pdf

http://www.youtube.com/watch?v=TaV1gL3xzbE

Expert Witnesses

Used by both prosecuting and defense attorneys to establish standards of care

Responsibility
Stay informed Hospital Policy & Procedures Board of Nursing Standards of Care

Source of Liability The medical record can change the entire climate surrounding a lawsuit Medical records, in themselves, may be the very source of a lawsuit

Documentation Standard Policy

Failure to Document False Documentation
Facility Policies Law(s)

Case in Point
Case Scenario

Master of Charting

Prevent a malpractice suit

The Basics
Chronology: Date and Time Client History Interventions: Medical, Social and Legal Observations: Objective and Subjective Outcomes Client and Family Response Authorship: Your Signature and Credentials

Legibility
Hand written
Cursive Print

Computerized
Typed notes Clicks

Date & Time

Sequence of Events Lapse in Time Late Entries Blocked Time Military vs Standard Time

Clients History
Including unhealthy conditions or risky heath habits such as:
scalp lice smoking failure to take prescribed medication, etc.

Subject & Objective

See Hear Feel Think

Changes in Health Status

Your actions Clients response Client outcomes

Client Outcomes
Expected Deviations

Expectation: Pain Scale

Documentation of Assessment

Actual Response
Evaluations Verbal Non-verbal

Your Signature
Full name Credentials Job title Initials

A Little More than The Basics

Client/Family Education/Instructions Referrals to Community Resources Authorizations and Consents Plans for Follow-up Discharge Plan Telephone Calls: Be Specific

Client Education

Family Significant Other

Standard Education

Referrals & Consents

Standard Consent Forms Referrals: Client Specific Facility Resources Community Resources

SBAR
S Situation B Background A Assessment R - Recommendation

Phone Calls
Phone Record Phone Orders Pager Response Documentation Facility Policy

Client Call Office Scenario

Date and time of call Caller's name and address Caller's request or chief complaint Advice you gave Protocol you followed (if any) Other caregivers you notified Your name

Client Call Hospital Scenario

Date and time of call Physicians name Clients chief complaint Information your provided Protocol you followed (SBAR) Orders received / not received

Read Back
Date and time of call Physician's name and "T/O" to indicate order Verbal order, written word-for-word Documentation that you've read back the order, to be sure you heard it correctly Documentation that you've transcribed it according to your facility's policy Your name

Faxes & Computerized Records

Facts on Faxing Records Computer Charting

Safeguards for Faxing

1. Check the number before you dial. 2. Check the number on the fax machine display. 3. Re-check the number before you press the send button.

Computerized Documentation
Easier form of communication Legible As legal as when you manually chart

Guide to Computer Documentation

Double-check entries Password security Do NOT share your code!

Guide to Computer Documentation

HIPPA computer display Log off Printouts P&P for computer entry errors Backup files
Galactica?

Guide to Computer Documentation

Patient data, Confidentiality, and Disclosure state's rules and regulations facility's policies and procedures permanent part of the medical record

Guide to Computer Documentation

Good computerized documentation not only can help you in court, but it can also keep you out of court in the first place.

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

RN * LPN * CNA Differences

RN Nursing process CNAs & LPNs
Flow charts & check lists

WHEN THE LICENSED NURSE DELEGATES PATIENT CARE ACTIVITIES TO UAPs

WHEN THE PHYSICIAN DELEGATES PATIENT CARE ACTIVITIES TO UAPs

RN
Care Plan Standardized Care Plan Clinical Pathway

Standardized Nursing Care Plan

Formatted - the nurse checks off care provided. The Nurse Individualizes the care plan specific to each patient

Clinical Care Path

Nursing actions for a specific medical diagnosis. Specifies daily care required
including but not limited to:
diet, medications, activity, treatments

The goal: progress to discharge

Kardex
Card system - readily accessible to all members of the health care team Quick reference

Computerized Kardex

Nurses Notes
Narrative SOAP SOAPIE SOAPIER APIE PIE Graphic Charting Focused Charting Charting by Exception

Nurses Notes Narrative

Narrative
Chronological Legibility Format

Universal Guideline for Charting Nursing Process Four phases of nursing care:
Assessment Planning Implementation Evaluation

Documentation Audits
Random Audits Quality / Performance Initiatives

How to prove Malpractice

Improper or negligent treatment of a patient, as by a physician, resulting in injury, damage, or loss. Improper or unethical conduct by the holder of a professional or official position. The act or an instance of improper practice.

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

Documentation The wrong way!

Legal situations

Ketchum vs. Overlake Hospital Medical Center

1991

Ms. Ketchum sued Overlake Hospital, contending that her severe mental retardation was caused by what she felt was negligent nursing care.

Expert Nurse Witness Prosecution

Assessment Documentation Report Changes

Expert Nurse Witness Defense

Assessment Documentation Report Changes

Pivotal Issue
Documentation

Jarvis vs. St. Charles Medical Center

1986

Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which was subsequently surgically reduced

Pivotal Issues

Reporting Problems Following Orders

Inconsistent Nurses Notes

Standard of Nursing Care
This case truly epitomizes the old saying that if the care was not documented, then it was not done
It was as though a nurse never checked the client during that time period.

Ard vs. East Jefferson General Hospital

Five days after quintuple coronary artery bypass graft surgery, a patient who was having respiratory problems was transferred out of the intensive care unit (ICU).

Nurse Availability Call Bell

Standard Practice

Wrongful Death

The basis for a lawsuit, which is filed due to a death caused by the negligence of another person

Nurse Expert
Breach in Standard of Care Failure to address high risk problem Failure to complete full assessment

Medical Expert
Change the Outcome

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

Professional Liability Coverage

http://www.nso.com/customer/faq_cov.php

Does having my own individual professional liability insurance policy make me a more likely target for a lawsuit?

Professional Liability Coverage

Why do I need an individual professional liability policy? Won't my employer's insurance coverage protect me?

Case Study Mock Trial

Judge & Jury

Examples
SOB / Difficulty Breathing Chest Pain Low BP / Change in LOC Lungs wet IVF wide open

References
1. 2. 3. Ashley, Ruthe C. Legal Counsel. Critical Care Nurse, Dec 2004 Charting Made Incredibly Easy. 2nd Edition. Lippincott Williams & Wilkins: Philadelphia, Pennsylvania, 2002 Feutz-Harter, Sheryl. Nursing Case Law Update: Faulty Documentation. Journal of Nursing Law, Vol.2 Issue Mary E. OKeefe, Nursing Practice and the Law (Philadelphia: F.A. Davis Company, 2001), 14041. Medi-Smart Nursing Education Resources: Nursing Legal Issues http://www.medi-smart.com/documentation.htm North Carolina Board of Nursing: http://www.ncbon.com/ Nurses Service Organization: www.nso.com

4.
5. 6. 7.