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Nursing Documentation Your License may depend on it! Shelia Duncan RN, CCRN Nov. 2007 February 2008 August 2008 November 2...
 
 
 
CE ANNOUNCEMENTS <ul><li>Participants must attend entire session to get CE Credit. </li></ul><ul><li>There are no influent...
Taking a Poll  <ul><li>Have you been involved in a patient (client) related lawsuit ? </li></ul><ul><li>Do you have profes...
<ul><li>A patient you cared for 9 months ago is unhappy with the outcome and has filed a malpractice lawsuit against you. ...
The Jury
 
 
 
 
 
Legal Case Studies <ul><li>http://www.nso.com/case/com_index.php </li></ul>
What does the “jurors”  see and hear?? <ul><li>http:// www.youtube.com/watch?v =97O7Od6F8PM   </li></ul><ul><li>Lawyer – t...
“ Duty of Care” <ul><li>Based on existence of the nurse-patient relationship </li></ul><ul><li>A legal status created when...
Breach of Duty <ul><li>Nurse’s care fell below the acceptable Standard of Care </li></ul><ul><li>Results: </li></ul><ul><l...
Nursing Negligence / Malpractice <ul><li>Any action by a nurse that falls below generally accepted standards of nursing ca...
Proximate Cause <ul><li>“ PROOF” </li></ul><ul><li>Requires that there be a  reasonably close connection  between the nurs...
Foreseeability <ul><li>Nurse has a responsibility to foresee harm before it occurs and eliminate risks </li></ul><ul><li>A...
Illusion of Negligence   <ul><li>Evidence of the truth as to what really happened is unavailable </li></ul>
Damages <ul><li>Compensated when: </li></ul><ul><li>Suffered loss or injury through the act, omission, or negligence of an...
 
Objectives <ul><li>Explain the importance of documentation as a health care provider. </li></ul><ul><li>Identify the legal...
Objectives <ul><li>8.  Identify RN’s liability for LPN & CNA’s. </li></ul><ul><li>9.  Identify how the nursing process imp...
Questions <ul><li>What do you want to know? </li></ul>
Who Cares? <ul><li>State Regulations </li></ul><ul><li>Federal Regulations </li></ul><ul><li>Client / Patient  </li></ul><...
&quot;if it's not documented it was  not done&quot;  <ul><li>To avoid litigation, health care providers must comply with e...
Standards of Care <ul><li>State & Federal Legislation / Statutes  </li></ul><ul><li>Practice Guidelines </li></ul>
North Carolina <ul><li>Know your state’s regulations & statues  </li></ul><ul><li>The Purpose </li></ul><ul><ul><li>to cla...
Learn  - CEUs
Practice
http://www.ncbon.com/Practice.asp
Prudent Nurse <ul><li>Knowledge </li></ul><ul><li>Skill </li></ul><ul><li>Care </li></ul><ul><li>Diligence </li></ul>
Liability:  Chain of Command <ul><li>The Nurse’s Duty to Intervene—Initiating the Chain of Command </li></ul>
What Is the Chain of Command? <ul><li>Specific  course of action involving administrative and clinical lines of authority ...
Chain of Command? <ul><li>Clear Understanding </li></ul><ul><li>Established Philosophy </li></ul><ul><li>Procedure & Polic...
Albemarle’s Philosophy
Albemarle’s Chain
 
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 ...
Initiation of the Chain… <ul><li>Nurse </li></ul><ul><ul><li>becomes concerned  </li></ul></ul><ul><li>Physician  </li></u...
Examples  Clinical Situations <ul><li>The dose of a medication is excessive or inadequate. </li></ul><ul><li>IV fluid orde...
Documenting This Process “Chain of Command” <ul><li>Record events and observations in the patient’s medical record in an o...
Policy & Procedure <ul><li>Well known by all  </li></ul><ul><li>Improves the quality of care </li></ul><ul><li>Improves pa...
Negligence? <ul><li>Practice guidelines </li></ul><ul><li>Facility policies/procedures   </li></ul>http://ahweb/intranet/P...
Expert Witnesses <ul><li>Used by both prosecuting and defense attorneys to establish standards of care </li></ul>
Responsibility <ul><li>Stay informed </li></ul><ul><li>Hospital Policy & Procedures </li></ul><ul><li>Board of Nursing </l...
Source of Liability <ul><li>The  medical record  can change the entire climate surrounding a lawsuit </li></ul><ul><li>Med...
Documentation Standard Policy <ul><li>Failure to Document </li></ul><ul><li>False Documentation </li></ul><ul><ul><li>Faci...
Case in Point <ul><li>Case Scenario </li></ul>
Master of Charting <ul><li>Prevent a malpractice suit </li></ul>
The Basics <ul><li>Chronology: Date and Time  </li></ul><ul><li>Client History </li></ul><ul><li>Interventions: Medical, S...
Legibility  <ul><li>Hand written </li></ul><ul><ul><li>Cursive </li></ul></ul><ul><ul><li>Print </li></ul></ul><ul><li>Com...
Date & Time <ul><li>Sequence of Events </li></ul><ul><li>Lapse in Time </li></ul><ul><li>Late Entries </li></ul><ul><li>Bl...
Client’s History <ul><li>Including unhealthy conditions or risky heath habits such as: </li></ul><ul><ul><li>scalp lice </...
Subject & Objective <ul><li>See </li></ul><ul><li>Hear </li></ul><ul><li>Feel </li></ul><ul><li>“Think” </li></ul>
Changes in Health Status <ul><li>Your actions </li></ul><ul><li>Clients response </li></ul><ul><li>Client outcomes </li></ul>
Client Outcomes <ul><li>Expected </li></ul><ul><li>Deviations </li></ul>Case in point:  pain
Expectation:  Pain Scale
Documentation of Assessment
Actual Response <ul><li>Evaluations </li></ul><ul><li>Verbal </li></ul><ul><li>Non-verbal </li></ul>
Your Signature <ul><li>Full name </li></ul><ul><li>Credentials </li></ul><ul><li>Job title </li></ul><ul><li>Initials </li...
A Little More than The Basics <ul><li>Client/Family Education/Instructions </li></ul><ul><li>Referrals to Community Resour...
Client Education <ul><li>Family </li></ul><ul><li>Significant Other </li></ul>
Standard Education
Referrals & Consents <ul><li>Standard Consent Forms </li></ul><ul><li>Referrals:  Client Specific </li></ul><ul><li>Facili...
Who witnesses the Signature
SBAR <ul><li>S – Situation </li></ul><ul><li>B – Background </li></ul><ul><li>A – Assessment </li></ul><ul><li>R - Recomme...
Phone Calls <ul><li>Phone Record </li></ul><ul><li>Phone Orders </li></ul><ul><li>Pager Response </li></ul><ul><li>Documen...
Client Call Office Scenario  <ul><li>Date and time of call </li></ul><ul><li>Caller's name and address </li></ul><ul><li>C...
Client Call Hospital Scenario  <ul><li>Date and time of call </li></ul><ul><li>Physician’s name </li></ul><ul><li>Client’s...
“Read Back”  <ul><li>  Date and time of call </li></ul><ul><li>  Physician's name and &quot;T/O&quot; to indicate order </...
Faxes & Computerized Records <ul><li>Facts on Faxing Records </li></ul><ul><li>Computer Charting </li></ul>
Safeguards for Faxing <ul><li> 1.  Check  the number before you dial. </li></ul><ul><li> 2.  Check  the number on the fax ...
Computerized Documentation <ul><li>Easier form of communication </li></ul><ul><li>Legible  </li></ul><ul><li>As legal as w...
Guide to  Computer Documentation <ul><li>Double-check entries </li></ul><ul><li>Password security  </li></ul><ul><li>Do NO...
Guide to  Computer Documentation <ul><li>“ HIPPA” computer display  </li></ul><ul><li>Log off  </li></ul><ul><li>Printouts...
Guide to  Computer Documentation <ul><li>Patient data, Confidentiality, and Disclosure   </li></ul><ul><li>state's rules a...
Guide to  Computer Documentation <ul><li>Good computerized documentation not only can help you in court, but it can also k...
Make Documentation Easier <ul><li>The Do’s </li></ul><ul><li>The Don’ts </li></ul>
The Do’s <ul><li>Correct Chart </li></ul><ul><li>Reflect the Nursing Process </li></ul><ul><li>Write Legibly </li></ul><ul...
Clear / Concise / Accurate <ul><li>Wrong Way :  Communication with patient's family begun today to specify the manner in w...
Clear / Concise / Accurate <ul><li>Right Way:  I contacted Mr. Boon’s wife at 1415 hours. I explained that his cardiac sta...
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>P...
Do’s <ul><li>Nursing Procedures </li></ul><ul><ul><li>Name of procedure </li></ul></ul><ul><ul><li>When it was performed <...
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...
Do’s <ul><li>Medication omission </li></ul><ul><li>Late Entry </li></ul><ul><li>Not Applicable </li></ul><ul><li>Charting ...
Do’s <ul><li>Approved abbreviations & symbols </li></ul><ul><li>Discharge instructions </li></ul><ul><li>Commonly misspell...
Do’s <ul><li>Continuation  </li></ul><ul><li>Triplicate / Carbonated Copies </li></ul>
The Don'ts <ul><li>Complaints </li></ul><ul><li>Opinions  </li></ul><ul><li>Altering the Record </li></ul>
Red Flags <ul><li>Adding Information </li></ul><ul><li>Dating the entry </li></ul><ul><ul><li>Dates / Times conflict </li>...
Don’t <ul><li>Unapproved Abbreviations </li></ul><ul><li>Shorthand </li></ul><ul><li>Vague </li></ul><ul><li>Excuses </li>...
Don’t <ul><li>Chart for someone else </li></ul><ul><li>Chart Opinions </li></ul><ul><li>Use Negative Language </li></ul>
Don’t <ul><li>Use vague terms </li></ul><ul><li>Chart ahead </li></ul><ul><li>Misspelled words  </li></ul><ul><li>Incorrec...
Don’t <ul><li>Chart staffing problems </li></ul><ul><li>Chart staff conflicts </li></ul><ul><li>Chart casual conversations...
Fraud <ul><li>  </li></ul><ul><li>Charting care that you haven't performed is considered fraud </li></ul>
When you make a Mistake <ul><li>White out / Eraser </li></ul><ul><li>The word “Error” </li></ul><ul><li>Correct the Entry ...
Don’t <ul><li>Leave empty lines / spaces </li></ul><ul><li>Write in the margins </li></ul><ul><li>Make reference to incide...
Don’t <ul><li>Use words that suggest that there is a client’s safety risk </li></ul><ul><li>Violate client confidentially ...
RN * LPN * CNA  Differences  <ul><li>RN – Nursing process </li></ul><ul><li>CNAs & LPNs  </li></ul><ul><ul><li>Flow charts...
WHEN THE  LICENSED NURSE DELEGATES  PATIENT CARE ACTIVITIES TO UAPs
WHEN THE  PHYSICIAN DELEGATES  PATIENT CARE ACTIVITIES TO UAPs
RN <ul><li>Care Plan </li></ul><ul><li>Standardized Care Plan </li></ul><ul><li>Clinical Pathway </li></ul>
Standardized Nursing Care Plan <ul><ul><ul><li>Formatted  - the nurse checks off care provided.  </li></ul></ul></ul><ul><...
Clinical Care Path <ul><ul><li>Nursing actions for a specific medical diagnosis.  </li></ul></ul><ul><ul><li>Specifies dai...
Kardex <ul><li>Card system  - readily accessible to all members of the health care team </li></ul><ul><li>Quick reference ...
Computerized Kardex
Nurses Notes <ul><li>Narrative  </li></ul><ul><li>SOAP </li></ul><ul><li>SOAPIE </li></ul><ul><li>SOAPIER </li></ul><ul><l...
Nurses Notes Narrative <ul><li>Narrative </li></ul><ul><ul><li>Chronological </li></ul></ul><ul><ul><li>Legibility </li></...
Universal Guideline for Charting “Nursing Process” <ul><li>Four phases of nursing care: </li></ul><ul><li>Assessment </li>...
Documentation Audits <ul><li>Random Audits </li></ul><ul><li>Quality / Performance Initiatives </li></ul>
How to prove Malpractice <ul><li>Improper or negligent treatment of a patient, as by a physician, resulting in injury, dam...
Common Charting Mistakes <ul><li>Failing to record pertinent health or drug information   </li></ul><ul><li>Failing to rec...
Common Charting Mistakes <ul><li>Failing to document a discontinued medication  </li></ul><ul><li>Failing to record drug r...
Failing to record pertinent health or drug information  <ul><li>The nurse neglected to record her patient’s penicillin all...
Failing to record nursing actions  <ul><li>The evening nurse notices heavy drainage from the wound.  </li></ul><ul><li>She...
Failing to record that medications have been given  <ul><li>A day nurse gave a patient heparin by intravenous push just be...
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. Mo...
Failing to document a discontinued medication   <ul><li>A doctor suspected that his patient, who was taking high doses of ...
Failing to record drug reactions or changes in the patient’s condition <ul><li>A patient complained of nausea, dizziness, ...
Transcribing orders improperly or transcribing improper orders  <ul><li>A doctor ordered 5 ml of atropine for a patient on...
Writing illegible or incomplete records  <ul><li>To play it safe: </li></ul><ul><li>Print  </li></ul><ul><li>Sign your ful...
Documentation – The wrong way! <ul><li>Legal situations </li></ul>
Ketchum vs. Overlake Hospital Medical Center   1991  <ul><li>Ms. Ketchum sued Overlake Hospital, contending that her sever...
Expert Nurse Witness Prosecution <ul><li>Assessment </li></ul><ul><li>Documentation </li></ul><ul><li>Report Changes </li>...
Expert Nurse Witness Defense <ul><li>Assessment </li></ul><ul><li>Documentation </li></ul><ul><li>Report Changes </li></ul>
Pivotal Issue <ul><li>Documentation </li></ul>
Jarvis vs. St. Charles Medical Center 1986  <ul><li>Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which...
Pivotal Issues <ul><li>Reporting Problems </li></ul><ul><li>Following Orders </li></ul>
Inconsistent Nurses Notes <ul><li>Standard of Nursing Care </li></ul><ul><li>This case truly epitomizes the old saying tha...
Ard vs. East Jefferson General Hospital   <ul><li>Five days after quintuple coronary artery bypass graft surgery, a patien...
Nurse Availability Call Bell <ul><li>Standard Practice </li></ul>
Wrongful Death <ul><li>The basis for a lawsuit, which is filed due to a death caused by the negligence of another person  ...
Nurse Expert <ul><li>Breach in Standard of Care </li></ul><ul><li>Failure to address high risk problem </li></ul><ul><li>F...
Medical Expert <ul><li>Change the Outcome </li></ul>
Lessons Learned <ul><li>Documentation validates Nursing Care </li></ul><ul><li>A high-risk patient requires complete asses...
Defensive Documentation <ul><li>Chronological </li></ul><ul><li>Comprehensive </li></ul><ul><li>Complete </li></ul><ul><li...
Future <ul><li>National Standards </li></ul>
Professional Liability Coverage <ul><li>Does having my own individual professional liability insurance policy make me a mo...
Professional Liability Coverage <ul><li>Why do I need an individual professional liability policy?  </li></ul><ul><li>Won'...
Case Study “Mock Trial” <ul><li>Judge & Jury </li></ul>
Examples <ul><li>SOB / Difficulty Breathing </li></ul><ul><li>Chest Pain </li></ul><ul><li>Low BP / Change in LOC </li></u...
Evaluation Post-Test
References <ul><li>Ashley, Ruthe C.  “Legal Counsel.”  Critical Care Nurse, Dec 2004 </li></ul><ul><li>Charting Made Incre...
 
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Legal Documentation Aug 2008

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Documentation: Your Best Defense

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  • Transcript of "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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