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  1. 1. Documentation Donna Adelsperger RN, M. Ed.
  2. 2. Definition of Documentation <ul><li>Defined as written evidence of the interactions between and among health professionals, patients, and their families; the administration of procedures, treatments, and diagnostic tests; the patient’s response to them and education of the family support unit. </li></ul>
  3. 3. Defensive Documentation <ul><li>Major purpose of the medical record is to document the care given to the patient </li></ul><ul><li>It also is the communication to all members of the health care team </li></ul><ul><li>Documents and support continuity of care from one professional to the another </li></ul><ul><li>Also a legal document </li></ul>
  4. 4. Defensive Documentation <ul><li>The chart is a very persuasive witness because it is the description of the facts at the time </li></ul><ul><li>There should be no unanswered questions in the patient’s record that plaintiff attorneys can use to construct their version of what happened </li></ul><ul><li>3 recommendations: DOCUMENT - DOCUMENT - DOCUMENT </li></ul>
  5. 5. Defensive Documentation <ul><li>(Perinatal) (pediatric)_All nurses should know that the inadequately documented medical record can be their worse liability </li></ul><ul><li>The well-documented medical record can be their greatest legal asset </li></ul>
  6. 6. Defensive Documentation <ul><li>Avoid using empty, meaningless charting phrases such as, “physician notified of patient’s condition” </li></ul><ul><li>When report given to MD, the nurse can expect that person (MD) to respond in timely fashion. </li></ul>
  7. 7. Defensive Documentation <ul><li>When communicating with a charge nurse or another nurse recognized as a resource documentation of discussion seen as consultation and should be documented. </li></ul><ul><li>Nurses rarely document this kind of communication </li></ul><ul><li>Can use chain of command only when there is sufficient time </li></ul>
  8. 8. Documentation- Top Tips <ul><li>Don’t squeeze information into the chart </li></ul><ul><li>Don’t write between the lines </li></ul><ul><li>If there is an error, draw a single line through it, date it, initial it </li></ul>
  9. 9. Documentation <ul><li>Documentation reflects: character, competency, and the care delivered by the nurse </li></ul><ul><li>In a courtroom the medical record will represent the nurse, rather than the nurses’ bedside manner or caring attitude </li></ul>
  10. 10. Documentation <ul><li>Verifies care given & status of the patient </li></ul><ul><li>Clearly depicts a complete picture of the patient </li></ul><ul><li>Ensures that quality of care provided is in accordance with professional nursing practice standards </li></ul><ul><li>Must be adequate, legible , timely and complete </li></ul>
  11. 11. Documentation <ul><li>All of the following can lead to the state licensing board suspending or revoking the nurse’s license: </li></ul><ul><ul><li>Failure to document entries on patient record </li></ul></ul><ul><ul><li>Falsification of patient records </li></ul></ul><ul><ul><li>Making incorrect entries </li></ul></ul>
  12. 12. Documentation <ul><li>Cases come to court a long time (usually) after the events occurred </li></ul><ul><li>Nurses, therefore have little or no recollection of the events surrounding the case and must rely on their documentation for what occurred </li></ul>
  13. 13. The Duty to Document <ul><li>Nurse Practice Acts state the general duty is to “record pertinent information including the response to interventions” </li></ul><ul><li>While the medical record is “owned” by the institution it is maintained for the benefit of the patient </li></ul><ul><li>Courts have held that poor documentation creates presumption of poor care </li></ul>
  14. 14. Intensive Documentation Required <ul><li>Sudden decline in patient’s condition </li></ul><ul><li>Patient injuries/medication errors </li></ul><ul><li>Equipment failure/incorrect use </li></ul><ul><li>Failure of provider to respond </li></ul><ul><li>The “red flag” patient or family </li></ul><ul><li>Unresolved disagreements in patient care between providers </li></ul>
  15. 15. Factors that Define Quality Documentation <ul><li>Frequency and completeness </li></ul><ul><ul><li>must follow the established rules of documentation </li></ul></ul><ul><ul><li>rules come from federal regulations, state statutes, accreditation boards, policies and procedures of the hospital and the standards set by professional organizations </li></ul></ul><ul><li>The chart must truly reflect that the standard of care for patient was met </li></ul>
  16. 16. Do Document the Following <ul><li>Patient behavior. Document description of noncompliant behavior </li></ul><ul><li>Use quotations when appropriate </li></ul><ul><li>Document neatly and legibly </li></ul>
  17. 17. Late Entries <ul><li>Add late entries at first available space </li></ul><ul><li>Document date and time the event occurred </li></ul><ul><li>Clearly identify the entry as a late one </li></ul>
  18. 18. Documentation <ul><li>Courts have issued a warning to nurses that the availability of accurate medical records is NOT a technicality but IS a legal requirement </li></ul><ul><li>According to a Charles Ward, MD, “in a courtroom the finest care rendered under the best circumstances may be difficult or impossible to defend if it is not documented” </li></ul>
  19. 19. Documentation <ul><li>Nurses’ communication skills lay the foundation for the care delivered to the patient </li></ul><ul><li>Nurses are key members of the health care team </li></ul><ul><li>Complexity of care is increasing, so complexity of nursing documentation increases </li></ul><ul><li>Perfecting skill of documentation is just as important as any other skill used in the clinical setting </li></ul>