Nursing Nursing DocumentationDocumentation

Your License may depend on it!Your License may depend on it!

Nelia B. Perez RN, MSNPCU - MJCN

Taking a Poll Taking a Poll

1. 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?

The CourtThe Court

Legal Case StudiesLegal Case Studies

““Duty of Care”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 DutyBreach of Duty

Nurse’s care fell below the acceptable Standard of Care

Results:

malpractice case – compensatory $$$

loss of nurse’s license

loss of job / ability to work

Nursing Negligence / Nursing Negligence / MalpracticeMalpractice

• Any action by a nurse that falls Any action by a nurse that falls below generally accepted standards below generally accepted standards of nursing care, and causes of nursing care, and causes injuryinjury to to a patienta patient

• Even if nurses actions were only Even if nurses actions were only contributing cause to the injurycontributing cause to the injury

Proximate CauseProximate Cause

“PROOF”

Requires that there be a reasonably close connection between the nurse’s conduct and the resultant injury

ForeseeabilityForeseeability

Nurse has a responsibility to foresee harm before it occurs and eliminate risks

• Admission Screens

• Fall Risk

• Suicide Risk

Illusion of NegligenceIllusion of Negligence

Evidence of the truth as Evidence of the truth as to what really happened to what really happened is unavailableis unavailable

DamagesDamages

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

ObjectivesObjectives1. 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.

ObjectivesObjectives8. 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 documentation 13. Discuss the future of documentation standards.14. Evaluate the medical record documentation issues in selected

legal cases.

QuestionsQuestions

• What do you want to know?

Who Cares?Who Cares?

• Regulations

• Client / Patient

• Insurance

"if it's not documented it was "if it's not documented it was not done" not done"

To avoid litigation, health care providers must comply with established standards of carestandards of care.

Standards of CareStandards of Care

• Legislation / Statutes

• Practice Guidelines

Prudent NursePrudent Nurse

• Knowledge

• Skill

• Care

• Diligence

Why Is the Chain of Command Why Is the Chain of Command Important?Important?

Courts have held that nurses have a duty to question a physician’s order if it is not consistent with standard medical standard medical practice. practice.

Initiation of the Chain…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 Examples Clinical SituationsClinical 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.

Make Documentation EasierMake Documentation Easier

• The Do’s

• The Don’ts

The Do’sThe Do’s

• Correct Chart

• Reflect the Nursing Process

• Write Legibly

• Permanent Black Ink

• Complete / Concise / Accurate

Clear / Concise / AccurateClear / Concise / Accurate

Wrong WayWrong 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 / AccurateClear / Concise / Accurate

Right Way: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.

Do’sDo’s

• Medications– Route– Client’s response

• Precautions / Preventive Measures– Side rails– Restraints

Do’sDo’s

• Nursing Procedures– Name of procedure– When it was performed– Who performed it– How it was performed– How well the client tolerated it– Adverse reactions

Do’sDo’s

• Phone calls

• Health Care Team visits

• Don’t wait to Chart

• Client refusals

• Client’s subjective data

Do’sDo’s

• Medication omission

• Late Entry

• Not Applicable

• Charting Frequency– Facility P&P / Standards

Do’sDo’s

• Approved abbreviations & symbols

• Discharge instructions

• Commonly misspelled words

• Look-a-Like / Sound-a-Like

Do’sDo’s

• Continuation

• Triplicate / Carbonated Copies

The Don'tsThe Don'ts

• Complaints

• Opinions

• Altering the Record

Red FlagsRed Flags

• Adding Information

• Dating the entry– Dates / Times conflict

• Inaccurate Information.

• Destroying records

Don’tDon’t

• Unapproved Abbreviations

• Shorthand

• Vague

• Excuses

Don’tDon’t

• Chart for someone else

• Chart Opinions

• Use Negative Language

Don’tDon’t

• Use vague terms

• Chart ahead

• Misspelled words

• Incorrect Grammar

Don’tDon’t

• Chart staffing problems

• Chart staff conflicts

• Chart casual conversations

FraudFraud

 

Charting care that you haven't performed is considered fraud

When you make a MistakeWhen you make a Mistake

• White out / Eraser

• The word “Error”

• Correct the Entry

• Oops

• Sad Faces

Don’tDon’t

• Leave empty lines / spaces

• Write in the margins

• Make reference to incident reports

Don’tDon’t

• Use words that suggest that there is a client’s safety risk

• Violate client confidentially– HIPPA

Common Charting MistakesCommon Charting Mistakes

• Failing to record Failing to record pertinent health or pertinent health or drug informationdrug information

• Failing to record Failing to record nursing actionsnursing actions

• Failing to record that Failing to record that medications have medications have been given been given

• Recording on the Recording on the wrong chart wrong chart

Common Charting MistakesCommon Charting Mistakes• Failing to document a Failing to document a

discontinued discontinued medication medication

• Failing to record drug Failing to record drug reactions or changes reactions or changes in the patient’s in the patient’s condition condition

• Transcribing orders Transcribing orders improperly or improperly or transcribing improper transcribing improper orders orders

• Writing illegible or Writing illegible or incomplete recordsincomplete records

Failing to record pertinent health Failing to record pertinent health or drug information or drug information

The nurse neglected to record The nurse neglected to record her patient’s penicillin her patient’s penicillin allergy in the admission allergy in the admission notes. notes.

Because the intern didn’t know Because the intern didn’t know the patient was penicillin-the patient was penicillin-allergic, he gave the patient allergic, he gave the patient a penicillin injection.a penicillin injection.

The patient, who was The patient, who was incoherent and couldn’t tell incoherent and couldn’t tell the intern about the allergy, the intern about the allergy, went into anaphylactic went into anaphylactic shock and suffered shock and suffered irreversible brain damage.irreversible brain damage.

At the trial, the court found the At the trial, the court found the nurse guilty of negligence.nurse guilty of negligence.

Failing to record nursing actions 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 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 Failing to record that medications have been given 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 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. 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 Failing to document a discontinued medicationdiscontinued 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 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 Failing to record drug reactions or changes in the patient’s or changes in the patient’s

conditioncondition

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 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 orders improperly or transcribing improper orders 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 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 Writing illegible or incomplete records records

To 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 CHARTINGMETHODS (STYLES) OF CHARTING

• NARRATIVE• SOAP

SOAPIER• FOCUS

DATA

ACTION

RESPONSE• PIE• EXCEPTION CHARTING

NARRATIVENARRATIVE

• CHRONOLOGICAL

• BASELINE CHARTED QSHIFT

• LENGTHY, TIME-CONSUMING

• SEPARATE PAGES FOR EACH

• SOURCE-ORIENTED

SOAPSOAP• 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 CHARTINGEXAMPLE 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 CHARTINGFOCUS 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 CHARTINGEXAMPLE 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 CHARTINGPIE 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 CHARTINGSAMPLE 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 EXCEPTIONCHARTING 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 CHARTINGCOMPUTERIZED 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.

KARDEXKARDEX

• QUICK REFERENCE

• CHANGED AS NEEDED

• NOT PART OF PERMANENT RECORD

ABBREVIATIONSABBREVIATIONS

• 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 REPORTCHANGE OF SHIFT REPORT

• PERSON TO PERSON

• BE PREPARED• AVOID

GOSSIP/SOCIALIZATION

• TAPE RECORDER

INCIDENT REPORTSINCIDENT 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 ERRORSCORRECTING 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.

Lessons LearnedLessons Learned

• Documentation validates Nursing Care

A high-risk patient requires complete assessment and frequent monitoring.

Defensive DocumentationDefensive Documentation

ChronologicalComprehensiveCompleteConciseDescriptiveFactual

 

Legally awareLegibleRelevance Standard

abbreviations, symbols, and terms

ThoroughTimely

Documentation – The right way!Documentation – The right way!

FutureFuture

• National Standards