Legal Documentation Aug 2008

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Documentation: Your Best Defense

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  • Legal Documentation Aug 2008

    1. 1. Nursing Documentation Your License may depend on it! Shelia Duncan RN, CCRN Nov. 2007 February 2008 August 2008 November 2008
    2. 5. CE ANNOUNCEMENTS <ul><li>Participants must attend entire session to get CE Credit. </li></ul><ul><li>There are no influential financial relationships, planners, and/or presenters. </li></ul><ul><li>There is no commercial support that has influenced the planning of this educational activity or content. </li></ul><ul><li>There is no endorsement of any product by NCNA associated with this program. </li></ul><ul><li>This program does not relate to products governed by the Food and Drug Administration. If, so appropriate and off-label use will be shared. </li></ul>
    3. 6. Taking a Poll <ul><li>Have you been involved in a patient (client) related lawsuit ? </li></ul><ul><li>Do you have professional liability insurance? </li></ul><ul><li>Do you feel like your documentation would support you in a court of law? </li></ul>
    4. 7. <ul><li>A patient you cared for 9 months ago is unhappy with the outcome and has filed a malpractice lawsuit against you. </li></ul><ul><li>Now what? </li></ul>
    5. 8. The Jury
    6. 14. Legal Case Studies <ul><li>http://www.nso.com/case/com_index.php </li></ul>
    7. 15. What does the “jurors” see and hear?? <ul><li>http:// www.youtube.com/watch?v =97O7Od6F8PM </li></ul><ul><li>Lawyer – types of med. Malpractice </li></ul><ul><li>http:// www.youtube.com/watch?v =S2qv5J2S3ec&NR=1 </li></ul><ul><li>Lawyer – explains med. Malpractice </li></ul><ul><li>http:// www.youtube.com/watch?v =226MGeCuHAY </li></ul><ul><li>News Clip – ER Death </li></ul><ul><li>http:// www.youtube.com/watch?v =2xQx24v48ME </li></ul><ul><li>Lawyer – good opening statement </li></ul>
    8. 16. “ Duty of Care” <ul><li>Based on existence of the nurse-patient relationship </li></ul><ul><li>A legal status created when the nurse is legally obligated to provide nursing care to a patient </li></ul><ul><li>Law will demand that the nurse perform as a reasonably prudent nurse </li></ul>
    9. 17. Breach of Duty <ul><li>Nurse’s care fell below the acceptable Standard of Care </li></ul><ul><li>Results: </li></ul><ul><li>malpractice case – compensatory $$$ </li></ul><ul><li>loss of nurse’s license </li></ul><ul><li>loss of job / ability to work </li></ul>
    10. 18. Nursing Negligence / Malpractice <ul><li>Any action by a nurse that falls below generally accepted standards of nursing care, and causes injury to a patient </li></ul><ul><li>Even if nurses actions were only contributing cause to the injury </li></ul>
    11. 19. Proximate Cause <ul><li>“ PROOF” </li></ul><ul><li>Requires that there be a reasonably close connection between the nurse’s conduct and the resultant injury </li></ul>
    12. 20. Foreseeability <ul><li>Nurse has a responsibility to foresee harm before it occurs and eliminate risks </li></ul><ul><li>Admission Screens </li></ul><ul><li>Fall Risk </li></ul><ul><li>Suicide Risk </li></ul>
    13. 21. Illusion of Negligence <ul><li>Evidence of the truth as to what really happened is unavailable </li></ul>
    14. 22. Damages <ul><li>Compensated when: </li></ul><ul><li>Suffered loss or injury through the act, omission, or negligence of another </li></ul><ul><ul><li>Medical costs </li></ul></ul><ul><ul><li>Loss of earnings </li></ul></ul><ul><ul><li>Impairment of future earnings </li></ul></ul><ul><ul><li>Past / future pain & suffering </li></ul></ul>
    15. 24. Objectives <ul><li>Explain the importance of documentation as a health care provider. </li></ul><ul><li>Identify the legal aspects of nursing documentation. </li></ul><ul><li>Identify the basic information that is required when documenting. </li></ul><ul><li>Describe specific issues that require documentation. </li></ul><ul><li>Discuss documentation concerns regarding faxing of records. </li></ul><ul><li>Discuss computerized documentation concerns. </li></ul><ul><li>Discuss documentation Do’s and Don’ts. </li></ul>
    16. 25. Objectives <ul><li>8. Identify RN’s liability for LPN & CNA’s. </li></ul><ul><li>9. Identify how the nursing process impacts nursing documentation. </li></ul><ul><li>State characteristics of reasonable documentation. </li></ul><ul><li>Explain what constitutes Nursing Malpractice related to the role of documentation. </li></ul><ul><li>Identify common charting errors. </li></ul><ul><li>Identify the consequences of poor documentation </li></ul><ul><li>Discuss the future of documentation standards. </li></ul><ul><li>Evaluate the medical record documentation issues in selected legal cases. </li></ul>
    17. 26. Questions <ul><li>What do you want to know? </li></ul>
    18. 27. Who Cares? <ul><li>State Regulations </li></ul><ul><li>Federal Regulations </li></ul><ul><li>Client / Patient </li></ul><ul><li>Reimbursement </li></ul>
    19. 28. &quot;if it's not documented it was not done&quot; <ul><li>To avoid litigation, health care providers must comply with established standards of care . </li></ul>
    20. 29. Standards of Care <ul><li>State & Federal Legislation / Statutes </li></ul><ul><li>Practice Guidelines </li></ul>
    21. 30. North Carolina <ul><li>Know your state’s regulations & statues </li></ul><ul><li>The Purpose </li></ul><ul><ul><li>to clarify the legal scope of practice & accountability </li></ul></ul>
    22. 31. Learn - CEUs
    23. 32. Practice
    24. 33. http://www.ncbon.com/Practice.asp
    25. 34. Prudent Nurse <ul><li>Knowledge </li></ul><ul><li>Skill </li></ul><ul><li>Care </li></ul><ul><li>Diligence </li></ul>
    26. 35. Liability: Chain of Command <ul><li>The Nurse’s Duty to Intervene—Initiating the Chain of Command </li></ul>
    27. 36. What Is the Chain of Command? <ul><li>Specific course of action involving administrative and clinical lines of authority </li></ul><ul><li>Established to ensure effective conflict resolution </li></ul>
    28. 37. Chain of Command? <ul><li>Clear Understanding </li></ul><ul><li>Established Philosophy </li></ul><ul><li>Procedure & Policy </li></ul><ul><li>Nurse’s responsibility to recognize problems with patient care and take appropriate action to prevent patient injury. </li></ul>
    29. 38. Albemarle’s Philosophy
    30. 39. Albemarle’s Chain
    31. 41. Why Is the Chain Important? <ul><li>Courts have held that nurses have a duty to question a physician’s order if it is not consistent with standard medical practice. </li></ul>
    32. 42. Initiation of the Chain… <ul><li>Nurse </li></ul><ul><ul><li>becomes concerned </li></ul></ul><ul><li>Physician </li></ul><ul><ul><li>unresponsive or insufficiently responsive </li></ul></ul><ul><ul><li>might not return a page </li></ul></ul><ul><ul><li>tells the nurse not to call again about the same problem, or informs the </li></ul></ul><ul><ul><li>nurse he or she will come in later </li></ul></ul>
    33. 43. Examples Clinical Situations <ul><li>The dose of a medication is excessive or inadequate. </li></ul><ul><li>IV fluid orders are incomplete or inconsistent. </li></ul><ul><li>The nurse is concerned about fetal heart rate monitoring in a patient in labor. </li></ul><ul><li>The postoperative laparoscopic cholecystectomy patient begins having symptoms of an acute abdominal process. </li></ul><ul><li>The patient has widely divergent intake versus urinary output. </li></ul><ul><li>The patient is allergic to the medication the physician orders. </li></ul>
    34. 44. Documenting This Process “Chain of Command” <ul><li>Record events and observations in the patient’s medical record in an objective and clear manner. </li></ul><ul><li>Document the specific facts, and carefully record the time of each entry as accurately as possible. </li></ul><ul><li>Avoid finger pointing and personal attacks on the physician. </li></ul>
    35. 45. Policy & Procedure <ul><li>Well known by all </li></ul><ul><li>Improves the quality of care </li></ul><ul><li>Improves patient outcomes </li></ul>
    36. 46. Negligence? <ul><li>Practice guidelines </li></ul><ul><li>Facility policies/procedures </li></ul>http://ahweb/intranet/Policies/Nursing%20Policies/Nursing%20Standards.pdf http:// www.youtube.com/watch?v =TaV1gL3xzbE
    37. 47. Expert Witnesses <ul><li>Used by both prosecuting and defense attorneys to establish standards of care </li></ul>
    38. 48. Responsibility <ul><li>Stay informed </li></ul><ul><li>Hospital Policy & Procedures </li></ul><ul><li>Board of Nursing </li></ul><ul><li>Standards of Care </li></ul>
    39. 49. Source of Liability <ul><li>The medical record can change the entire climate surrounding a lawsuit </li></ul><ul><li>Medical records, in themselves, may be the very source of a lawsuit </li></ul>
    40. 50. Documentation Standard Policy <ul><li>Failure to Document </li></ul><ul><li>False Documentation </li></ul><ul><ul><li>Facility Policies </li></ul></ul><ul><ul><li>Law(s) </li></ul></ul>
    41. 51. Case in Point <ul><li>Case Scenario </li></ul>
    42. 52. Master of Charting <ul><li>Prevent a malpractice suit </li></ul>
    43. 53. The Basics <ul><li>Chronology: Date and Time </li></ul><ul><li>Client History </li></ul><ul><li>Interventions: Medical, Social and Legal </li></ul><ul><li>Observations: Objective and Subjective </li></ul><ul><li>Outcomes </li></ul><ul><li>Client and Family Response </li></ul><ul><li>Authorship: Your Signature and Credentials </li></ul>
    44. 54. Legibility <ul><li>Hand written </li></ul><ul><ul><li>Cursive </li></ul></ul><ul><ul><li>Print </li></ul></ul><ul><li>Computerized </li></ul><ul><ul><li>Typed notes </li></ul></ul><ul><ul><li>Clicks </li></ul></ul>
    45. 55. Date & Time <ul><li>Sequence of Events </li></ul><ul><li>Lapse in Time </li></ul><ul><li>Late Entries </li></ul><ul><li>Blocked Time </li></ul><ul><li>Military vs Standard Time </li></ul>
    46. 56. Client’s History <ul><li>Including unhealthy conditions or risky heath habits such as: </li></ul><ul><ul><li>scalp lice </li></ul></ul><ul><ul><li>smoking </li></ul></ul><ul><ul><li>failure to take prescribed medication, etc. </li></ul></ul>
    47. 57. Subject & Objective <ul><li>See </li></ul><ul><li>Hear </li></ul><ul><li>Feel </li></ul><ul><li>“Think” </li></ul>
    48. 58. Changes in Health Status <ul><li>Your actions </li></ul><ul><li>Clients response </li></ul><ul><li>Client outcomes </li></ul>
    49. 59. Client Outcomes <ul><li>Expected </li></ul><ul><li>Deviations </li></ul>Case in point: pain
    50. 60. Expectation: Pain Scale
    51. 61. Documentation of Assessment
    52. 62. Actual Response <ul><li>Evaluations </li></ul><ul><li>Verbal </li></ul><ul><li>Non-verbal </li></ul>
    53. 63. Your Signature <ul><li>Full name </li></ul><ul><li>Credentials </li></ul><ul><li>Job title </li></ul><ul><li>Initials </li></ul>Shelia Duncan RN, CCRN - SD ICU Educator
    54. 64. A Little More than The Basics <ul><li>Client/Family Education/Instructions </li></ul><ul><li>Referrals to Community Resources </li></ul><ul><li>Authorizations and Consents </li></ul><ul><li>Plans for Follow-up </li></ul><ul><li>Discharge Plan </li></ul><ul><li>Telephone Calls: Be Specific </li></ul>
    55. 65. Client Education <ul><li>Family </li></ul><ul><li>Significant Other </li></ul>
    56. 66. Standard Education
    57. 67. Referrals & Consents <ul><li>Standard Consent Forms </li></ul><ul><li>Referrals: Client Specific </li></ul><ul><li>Facility Resources </li></ul><ul><li>Community Resources </li></ul>
    58. 68. Who witnesses the Signature
    59. 69. SBAR <ul><li>S – Situation </li></ul><ul><li>B – Background </li></ul><ul><li>A – Assessment </li></ul><ul><li>R - Recommendation </li></ul>Communication
    60. 70. Phone Calls <ul><li>Phone Record </li></ul><ul><li>Phone Orders </li></ul><ul><li>Pager Response </li></ul><ul><li>Documentation </li></ul><ul><li>Facility Policy </li></ul>Communication
    61. 71. Client Call Office Scenario <ul><li>Date and time of call </li></ul><ul><li>Caller's name and address </li></ul><ul><li>Caller's request or chief complaint </li></ul><ul><li>Advice you gave </li></ul><ul><li>Protocol you followed (if any) </li></ul><ul><li>Other caregivers you notified </li></ul><ul><li>Your name </li></ul>Communication
    62. 72. Client Call Hospital Scenario <ul><li>Date and time of call </li></ul><ul><li>Physician’s name </li></ul><ul><li>Client’s chief complaint </li></ul><ul><li>Information your provided </li></ul><ul><li>Protocol you followed (SBAR) </li></ul><ul><li>Order’s received / not received </li></ul>Communication
    63. 73. “Read Back” <ul><li>  Date and time of call </li></ul><ul><li>  Physician's name and &quot;T/O&quot; to indicate order </li></ul><ul><li>  Verbal order, written word-for-word </li></ul><ul><li>  Documentation that you've read back the order, to be sure you heard it correctly </li></ul><ul><li>Documentation that you've transcribed it according to your facility's policy </li></ul><ul><li>Your name </li></ul>Communication
    64. 74. Faxes & Computerized Records <ul><li>Facts on Faxing Records </li></ul><ul><li>Computer Charting </li></ul>
    65. 75. Safeguards for Faxing <ul><li> 1.  Check the number before you dial. </li></ul><ul><li> 2.  Check the number on the fax machine display. </li></ul><ul><li> 3.  Re-check the number before you press the “send” button. </li></ul>
    66. 76. Computerized Documentation <ul><li>Easier form of communication </li></ul><ul><li>Legible </li></ul><ul><li>As legal as when you manually chart </li></ul>
    67. 77. Guide to Computer Documentation <ul><li>Double-check entries </li></ul><ul><li>Password security </li></ul><ul><li>Do NOT share your code! </li></ul>
    68. 78. Guide to Computer Documentation <ul><li>“ HIPPA” computer display </li></ul><ul><li>Log off </li></ul><ul><li>Printouts </li></ul><ul><li>P&P for computer entry errors </li></ul><ul><li>Backup files </li></ul><ul><ul><li>Galactica? </li></ul></ul>
    69. 79. Guide to Computer Documentation <ul><li>Patient data, Confidentiality, and Disclosure </li></ul><ul><li>state's rules and regulations </li></ul><ul><li>facility's policies and procedures </li></ul><ul><li>permanent part of the medical record </li></ul>
    70. 80. Guide to Computer Documentation <ul><li>Good computerized documentation not only can help you in court, but it can also keep you out of court in the first place. </li></ul>
    71. 81. Make Documentation Easier <ul><li>The Do’s </li></ul><ul><li>The Don’ts </li></ul>
    72. 82. The Do’s <ul><li>Correct Chart </li></ul><ul><li>Reflect the Nursing Process </li></ul><ul><li>Write Legibly </li></ul><ul><li>Permanent Black Ink </li></ul><ul><li>Complete / Concise / Accurate </li></ul>
    73. 83. Clear / Concise / Accurate <ul><li>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. </li></ul>
    74. 84. Clear / Concise / Accurate <ul><li>Right 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. </li></ul>
    75. 85. Do’s <ul><li>Medications </li></ul><ul><ul><li>Route </li></ul></ul><ul><ul><li>Client’s response </li></ul></ul><ul><li>Precautions / Preventive Measures </li></ul><ul><ul><li>Side rails </li></ul></ul><ul><ul><li>Restraints </li></ul></ul>
    76. 86. Do’s <ul><li>Nursing Procedures </li></ul><ul><ul><li>Name of procedure </li></ul></ul><ul><ul><li>When it was performed </li></ul></ul><ul><ul><li>Who performed it </li></ul></ul><ul><ul><li>How it was performed </li></ul></ul><ul><ul><li>How well the client tolerated it </li></ul></ul><ul><ul><li>Adverse reactions </li></ul></ul>
    77. 87. Do’s <ul><li>Phone calls </li></ul><ul><li>Health Care Team visits </li></ul><ul><li>Don’t wait to Chart </li></ul><ul><li>Client refusals </li></ul><ul><li>Client’s subjective data </li></ul>
    78. 88. Do’s <ul><li>Medication omission </li></ul><ul><li>Late Entry </li></ul><ul><li>Not Applicable </li></ul><ul><li>Charting Frequency </li></ul><ul><ul><li>Facility P&P / Standards </li></ul></ul>
    79. 89. Do’s <ul><li>Approved abbreviations & symbols </li></ul><ul><li>Discharge instructions </li></ul><ul><li>Commonly misspelled words </li></ul><ul><li>Look-a-Like / Sound-a-Like </li></ul>
    80. 90. Do’s <ul><li>Continuation </li></ul><ul><li>Triplicate / Carbonated Copies </li></ul>
    81. 91. The Don'ts <ul><li>Complaints </li></ul><ul><li>Opinions </li></ul><ul><li>Altering the Record </li></ul>
    82. 92. Red Flags <ul><li>Adding Information </li></ul><ul><li>Dating the entry </li></ul><ul><ul><li>Dates / Times conflict </li></ul></ul><ul><li>Inaccurate Information. </li></ul><ul><li>Destroying records </li></ul>
    83. 93. Don’t <ul><li>Unapproved Abbreviations </li></ul><ul><li>Shorthand </li></ul><ul><li>Vague </li></ul><ul><li>Excuses </li></ul>
    84. 94. Don’t <ul><li>Chart for someone else </li></ul><ul><li>Chart Opinions </li></ul><ul><li>Use Negative Language </li></ul>
    85. 95. Don’t <ul><li>Use vague terms </li></ul><ul><li>Chart ahead </li></ul><ul><li>Misspelled words </li></ul><ul><li>Incorrect Grammar </li></ul>
    86. 96. Don’t <ul><li>Chart staffing problems </li></ul><ul><li>Chart staff conflicts </li></ul><ul><li>Chart casual conversations </li></ul>
    87. 97. Fraud <ul><li>  </li></ul><ul><li>Charting care that you haven't performed is considered fraud </li></ul>
    88. 98. When you make a Mistake <ul><li>White out / Eraser </li></ul><ul><li>The word “Error” </li></ul><ul><li>Correct the Entry </li></ul><ul><li>Oops </li></ul><ul><li>Sad Faces </li></ul>Don't
    89. 99. Don’t <ul><li>Leave empty lines / spaces </li></ul><ul><li>Write in the margins </li></ul><ul><li>Make reference to incident reports </li></ul>
    90. 100. Don’t <ul><li>Use words that suggest that there is a client’s safety risk </li></ul><ul><li>Violate client confidentially </li></ul><ul><ul><li>HIPPA </li></ul></ul>
    91. 101. RN * LPN * CNA Differences <ul><li>RN – Nursing process </li></ul><ul><li>CNAs & LPNs </li></ul><ul><ul><li>Flow charts & check lists </li></ul></ul>
    92. 102. WHEN THE LICENSED NURSE DELEGATES PATIENT CARE ACTIVITIES TO UAPs
    93. 103. WHEN THE PHYSICIAN DELEGATES PATIENT CARE ACTIVITIES TO UAPs
    94. 104. RN <ul><li>Care Plan </li></ul><ul><li>Standardized Care Plan </li></ul><ul><li>Clinical Pathway </li></ul>
    95. 105. Standardized Nursing Care Plan <ul><ul><ul><li>Formatted - the nurse checks off care provided. </li></ul></ul></ul><ul><ul><ul><li>The Nurse Individualizes the care plan specific to each patient </li></ul></ul></ul>
    96. 106. Clinical Care Path <ul><ul><li>Nursing actions for a specific medical diagnosis. </li></ul></ul><ul><ul><li>Specifies daily care required </li></ul></ul><ul><ul><ul><li>including but not limited to: </li></ul></ul></ul><ul><ul><ul><ul><li>diet, medications, activity, treatments </li></ul></ul></ul></ul><ul><ul><li>The goal: progress to discharge </li></ul></ul>
    97. 107. Kardex <ul><li>Card system - readily accessible to all members of the health care team </li></ul><ul><li>Quick reference </li></ul>
    98. 108. Computerized Kardex
    99. 109. Nurses Notes <ul><li>Narrative </li></ul><ul><li>SOAP </li></ul><ul><li>SOAPIE </li></ul><ul><li>SOAPIER </li></ul><ul><li>APIE </li></ul><ul><li>PIE </li></ul><ul><li>Graphic Charting </li></ul><ul><li>Focused Charting </li></ul><ul><li>Charting by Exception </li></ul>
    100. 110. Nurses Notes Narrative <ul><li>Narrative </li></ul><ul><ul><li>Chronological </li></ul></ul><ul><ul><li>Legibility </li></ul></ul><ul><ul><li>Format </li></ul></ul>
    101. 111. Universal Guideline for Charting “Nursing Process” <ul><li>Four phases of nursing care: </li></ul><ul><li>Assessment </li></ul><ul><li>Planning </li></ul><ul><li>Implementation </li></ul><ul><li>Evaluation </li></ul>
    102. 112. Documentation Audits <ul><li>Random Audits </li></ul><ul><li>Quality / Performance Initiatives </li></ul>
    103. 113. How to prove Malpractice <ul><li>Improper or negligent treatment of a patient, as by a physician, resulting in injury, damage, or loss. </li></ul><ul><li>Improper or unethical conduct by the holder of a professional or official position. </li></ul><ul><li>The act or an instance of improper practice. </li></ul>Webster States:
    104. 114. Common Charting Mistakes <ul><li>Failing to record pertinent health or drug information </li></ul><ul><li>Failing to record nursing actions </li></ul><ul><li>Failing to record that medications have been given </li></ul><ul><li>Recording on the wrong chart </li></ul>
    105. 115. Common Charting Mistakes <ul><li>Failing to document a discontinued medication </li></ul><ul><li>Failing to record drug reactions or changes in the patient’s condition </li></ul><ul><li>Transcribing orders improperly or transcribing improper orders </li></ul><ul><li>Writing illegible or incomplete records </li></ul>
    106. 116. Failing to record pertinent health or drug information <ul><li>The nurse neglected to record her patient’s penicillin allergy in the admission notes. </li></ul><ul><li>Because the intern didn’t know the patient was penicillin-allergic, he gave the patient a penicillin injection. </li></ul><ul><li>The patient, who was incoherent and couldn’t tell the intern about the allergy, went into anaphylactic shock and suffered irreversible brain damage. </li></ul><ul><li>At the trial, the court found the nurse guilty of negligence. </li></ul>
    107. 117. Failing to record nursing actions <ul><li>The evening nurse notices heavy drainage from the wound. </li></ul><ul><li>She checks the nurses’ notes and finds no evidence that the dressing was changed. </li></ul><ul><li>She considers the amount of drainage normal for a period of several hours. </li></ul><ul><li>She changes the dressing but, like the day nurse, forgets to chart her action. </li></ul><ul><li>The night nurse does the same. </li></ul><ul><li>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. </li></ul>
    108. 118. Failing to record that medications have been given <ul><li>A day nurse gave a patient heparin by intravenous push just before she went off duty. </li></ul><ul><li>An hour later, the evening nurse saw the order for heparin--but no indication that it had been given. </li></ul><ul><li>So she gave the patient the same dose. </li></ul><ul><li>The patient began to hemorrhage and went into hypovolemic shock. </li></ul><ul><li>He recovered--then successfully sued the hospital. </li></ul>
    109. 119. Recording on the wrong chart <ul><li>Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. </li></ul><ul><li>Mrs. B. Moyer was being treated for severe hypertension; </li></ul><ul><li>Mrs. C. Moyer, for acute thrombophlebitis. </li></ul><ul><li>Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her. </li></ul><ul><li>The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin. </li></ul><ul><li>Mrs. B. Moyer started bleeding. </li></ul>
    110. 120. Failing to document a discontinued medication <ul><li>A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer. </li></ul><ul><li>So he discontinued the medication. </li></ul><ul><li>But the patient’s nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin. </li></ul><ul><li>The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. </li></ul><ul><li>She sued the hospital for the nurses’ negligence and won. </li></ul>
    111. 121. Failing to record drug reactions or changes in the patient’s condition <ul><li>A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). </li></ul><ul><li>His nurse wasn’t concerned, though. </li></ul><ul><li>By evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and early symptoms of shock. </li></ul><ul><li>He sued his nurse for negligence. </li></ul>
    112. 122. Transcribing orders improperly or transcribing improper orders <ul><li>A doctor ordered 5 ml of atropine for a patient on the coronary care unit. </li></ul><ul><li>He meant to order 0.5 ml, but he didn’t include the zero or write the decimal point clearly. </li></ul><ul><li>The nurse transcribed the order as 5 ml, although she didn’t think it seemed right. </li></ul><ul><li>She decided the doctor knew best and didn’t check the dose before recording it. </li></ul>
    113. 123. Writing illegible or incomplete records <ul><li>To play it safe: </li></ul><ul><li>Print </li></ul><ul><li>Sign your full name and title </li></ul><ul><li>Don’t leave blank spaces, lines, or boxes on charts </li></ul><ul><li>Don’t use unapproved abbreviations </li></ul><ul><li>Record every nursing action as soon as possible </li></ul><ul><li>Write enough to convince the reader </li></ul>
    114. 124. Documentation – The wrong way! <ul><li>Legal situations </li></ul>
    115. 125. Ketchum vs. Overlake Hospital Medical Center 1991 <ul><li>Ms. Ketchum sued Overlake Hospital, contending that her severe mental retardation was caused by what she felt was negligent nursing care. </li></ul>
    116. 126. Expert Nurse Witness Prosecution <ul><li>Assessment </li></ul><ul><li>Documentation </li></ul><ul><li>Report Changes </li></ul>
    117. 127. Expert Nurse Witness Defense <ul><li>Assessment </li></ul><ul><li>Documentation </li></ul><ul><li>Report Changes </li></ul>
    118. 128. Pivotal Issue <ul><li>Documentation </li></ul>
    119. 129. Jarvis vs. St. Charles Medical Center 1986 <ul><li>Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which was subsequently surgically reduced </li></ul>
    120. 130. Pivotal Issues <ul><li>Reporting Problems </li></ul><ul><li>Following Orders </li></ul>
    121. 131. Inconsistent Nurses Notes <ul><li>Standard of Nursing Care </li></ul><ul><li>This case truly epitomizes the old saying that if the care was not documented, then it was not done </li></ul><ul><li>It was as though a nurse never checked the client during that time period. </li></ul>
    122. 132. Ard vs. East Jefferson General Hospital <ul><li>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). </li></ul>
    123. 133. Nurse Availability Call Bell <ul><li>Standard Practice </li></ul>
    124. 134. Wrongful Death <ul><li>The basis for a lawsuit, which is filed due to a death caused by the negligence of another person </li></ul>
    125. 135. Nurse Expert <ul><li>Breach in Standard of Care </li></ul><ul><li>Failure to address high risk problem </li></ul><ul><li>Failure to complete full assessment </li></ul>
    126. 136. Medical Expert <ul><li>Change the Outcome </li></ul>
    127. 137. Lessons Learned <ul><li>Documentation validates Nursing Care </li></ul><ul><li>A high-risk patient requires complete assessment and frequent monitoring. </li></ul>
    128. 138. Defensive Documentation <ul><li>Chronological </li></ul><ul><li>Comprehensive </li></ul><ul><li>Complete </li></ul><ul><li>Concise </li></ul><ul><li>Descriptive </li></ul><ul><li>Factual   </li></ul><ul><li>Legally aware </li></ul><ul><li>Legible </li></ul><ul><li>Relevance </li></ul><ul><li>Standard abbreviations, symbols, and terms </li></ul><ul><li>Thorough </li></ul><ul><li>Timely </li></ul>Documentation – The right way!
    129. 139. Future <ul><li>National Standards </li></ul>
    130. 140. Professional Liability Coverage <ul><li>Does having my own individual professional liability insurance policy make me a more likely target for a lawsuit? </li></ul>http://www.nso.com/customer/faq_cov.php
    131. 141. Professional Liability Coverage <ul><li>Why do I need an individual professional liability policy? </li></ul><ul><li>Won't my employer's insurance coverage protect me? </li></ul>
    132. 142. Case Study “Mock Trial” <ul><li>Judge & Jury </li></ul>
    133. 143. Examples <ul><li>SOB / Difficulty Breathing </li></ul><ul><li>Chest Pain </li></ul><ul><li>Low BP / Change in LOC </li></ul><ul><li>Lungs “wet” – IVF wide open </li></ul>
    134. 144. Evaluation Post-Test
    135. 145. References <ul><li>Ashley, Ruthe C. “Legal Counsel.” Critical Care Nurse, Dec 2004 </li></ul><ul><li>Charting Made Incredibly Easy. 2 nd Edition. Lippincott Williams & Wilkins: Philadelphia, Pennsylvania, 2002 </li></ul><ul><li>Feutz-Harter, Sheryl. “Nursing Case Law Update: Faulty Documentation.” Journal of Nursing Law, Vol.2 Issue </li></ul><ul><li>Mary E. O’Keefe, Nursing Practice and the Law </li></ul><ul><li>(Philadelphia: F.A. Davis Company, 2001), 140–41. </li></ul><ul><li>5. Medi-Smart Nursing Education Resources: “Nursing Legal Issues” http://www.medi-smart.com/documentation.htm </li></ul><ul><li>6. North Carolina Board of Nursing: http://www.ncbon.com/ </li></ul><ul><li>7. Nurses Service Organization: www.nso.com </li></ul>

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