Nursing DocumentationYour License may depend on it! Nelia B. Perez RN, MSN PCU - MJCN
Taking a Poll1. 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?
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 DutyNurse’s care fell below the acceptable Standard of CareResults: malpractice case – compensatory $$$ loss of nurse’s 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 nurse’s conduct and the resultant injury
ForeseeabilityNurse has a responsibility to foresee harm before it occurs and eliminate risks• Admission Screens• Fall Risk• Suicide Risk
Illusion of NegligenceEvidence of the truth as to what really happened is unavailable
DamagesCompensated 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
Objectives1. 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 Do’s and Don’ts.
Objectives8. 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 documentation13. 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 its not documented it was not done"To avoid litigation, health care providers must comply with established standards of care. 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 physician’s 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 • The postoperative medication is laparoscopic excessive or cholecystectomy inadequate. patient begins having• IV fluid orders are symptoms of an acute incomplete or abdominal process. inconsistent. • The patient has widely• The nurse is divergent intake concerned about fetal versus urinary output. heart rate monitoring • The patient is allergic in a patient in labor. to the medication the physician orders.
Make Documentation Easier • The Do’s • The Don’ts
The Do’s• Correct Chart• Reflect the Nursing Process• Write Legibly• Permanent Black Ink• Complete / Concise / Accurate
Clear / Concise / AccurateWrong Way: Communication with Way patients family begun today to specify the manner in which his condition is progressing and suggest a probable consequence of that progression.
Clear / Concise / AccurateRight Way: I contacted Mr. Boon’s 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.
FraudCharting care that you havent performed is considered fraud
When you make a Mistake• White out / Eraser• The word “Error”• Correct the Entry• Oops• Sad Faces
Don’t• Leave empty lines / spaces• Write in the margins• Make reference to incident reports
Don’t• Use words that suggest that there is a client’s 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 patient’s condition• Transcribing orders improperly or transcribing improper orders• Writing illegible or incomplete records
Failing to record pertinent health or drug informationThe nurse neglected to record her patient’s penicillin allergy in the admission notes.Because the intern didn’t know the patient was penicillin- allergic, he gave the patient a penicillin injection.The patient, who was incoherent and couldn’t 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 actionsThe 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 patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should.
Failing to record that medications have been givenA 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 chartMrs. 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. Moyer’s doctor ordered 4,000 units of heparin for her.The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin.Mrs. B. Moyer started bleeding.
Failing to document a discontinued medicationA 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 patient’s 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 patient’s conditionA patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin).His nurse wasn’t 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 ordersA doctor ordered 5 ml of atropine for a patient on the coronary care unit.He meant to order 0.5 ml, but he didn’t include the zero or write the decimal point clearly.The nurse transcribed the order as 5 ml, although she didn’t think it seemed right.She decided the doctor knew best and didn’t check the dose before recording it.
Writing illegible or incomplete recordsTo play it safe:• Print• Sign your full name and title• Don’t leave blank spaces, lines, or boxes on charts• Don’t 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 FACILITY’S 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.