Nursing Nursing DocumentationDocumentation

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

CE ANNOUNCEMENTSCE ANNOUNCEMENTSParticipants must attend entire

session to get CE Credit.There are no influential financial

relationships, planners, and/or presenters.

There is no commercial support that has influenced the planning of this

educational activity or content.There is no endorsement of any

product by NCNA associated with this program.

This program does not relate to products governed by the Food and

Drug Administration. If, so appropriate and off-label use will be shared.

Taking a Poll Taking a Poll

1. Have you been involved in a patient (client) related lawsuit ?

2. Do you have professional liability insurance?

3. 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 JuryThe Jury

Legal Case StudiesLegal Case Studieshttp://www.nso.com/case/com_index.php

What does the “jurors” What does the “jurors” see and hear??see and hear??

http://www.youtube.com/watch?v=97O7Od6F8PM

Lawyer – types of med. MalpracticeLawyer – types of med. Malpractice

http://www.youtube.com/watch?v=S2qv5J2S3ec&NR=1

Lawyer – explains med. MalpracticeLawyer – explains med. Malpractice

http://www.youtube.com/watch?v=226MGeCuHAY

News Clip – ER DeathNews Clip – ER Death

http://www.youtube.com/watch?v=2xQx24v48ME

Lawyer – good opening statementLawyer – good opening statement

““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 RN’s liability for LPN & CNA’s.9. Identify how the nursing process impacts nursing documentation.10. State characteristics of reasonable documentation.11. Explain what constitutes Nursing Malpractice related to the role

of documentation.12. Identify common charting errors.13. Identify the consequences of poor documentation 14. Discuss the future of documentation standards.15. Evaluate the medical record documentation issues in selected

legal cases.

QuestionsQuestions

• What do you want to know?

Who Cares?Who Cares?

• State Regulations

• Federal Regulations

• Client / Patient

• Reimbursement

"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

• State & Federal Legislation / Statutes

• Practice Guidelines

North CarolinaNorth Carolina

• Know your state’s regulations & statues

• The Purpose– to clarify the legal scope of practice &

accountability

Learn - CEUsLearn - CEUs

PracticePractice

http://www.ncbon.com/Practice.asphttp://www.ncbon.com/Practice.asp

Prudent NursePrudent Nurse

• Knowledge

• Skill

• Care

• Diligence

Liability: Chain of CommandLiability: Chain of Command

The Nurse’s Duty to Intervene—Initiating the Chain of Command

What Is the Chain of What Is the Chain of Command?Command?

Specific course of action involving administrative and clinical lines of authority

Established to ensure effective conflict resolution

Chain of Command?Chain of Command?

• Clear Understanding• Established Philosophy• Procedure & Policy

Nurse’s responsibility to recognizerecognize problems with patient care and take appropriate actionaction to prevent patient injury.

Albemarle’s PhilosophyAlbemarle’s Philosophy

Albemarle’s ChainAlbemarle’s Chain

Why Is the Chain Important?Why Is the Chain 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.

Documenting This ProcessDocumenting This Process“Chain of Command”“Chain of Command”

• Record events and observations in the patient’s medical record in an objective and clear manner.

• Document the specific facts, and carefully record the time of each entry as accurately as possible.

• Avoid finger pointing and personal attacks on the physician.

Policy & ProcedurePolicy & Procedure

Well known by all Well known by all

Improves the quality of careImproves the quality of care

Improves patient outcomesImproves patient outcomes

Negligence?Negligence?

• Practice guidelines

• Facility policies/procedures

http://ahweb/intranet/Policies/Nursing%20Policies/Nursing%20Standards.pdf

http://www.youtube.com/watch?v=TaV1gL3xzbE

Expert WitnessesExpert Witnesses

• Used by both prosecuting and defense attorneys to establish standards of care

ResponsibilityResponsibility

• Stay informed

• Hospital Policy & Procedures

• Board of Nursing

• Standards of Care

Source of LiabilitySource of Liability

• The medical record can change the entire climate surrounding a lawsuit

• Medical records, in themselves, may be the very source of a lawsuit

Documentation Standard PolicyDocumentation Standard Policy

• Failure to Document

• False Documentation– Facility Policies– Law(s)

Case in PointCase in Point

• Case Scenario

Master of ChartingMaster of Charting

• Prevent a malpractice suit

The BasicsThe Basics

• Chronology: Date and Time • Client History• Interventions: Medical, Social and Legal• Observations: Objective and Subjective• Outcomes• Client and Family Response• Authorship: Your Signature and Credentials

Legibility Legibility

• Hand written– Cursive– Print

• Computerized– Typed notes– Clicks

Date & TimeDate & Time

• Sequence of Events

• Lapse in Time

• Late Entries

• Blocked Time

• Military vs Standard Time

Client’s HistoryClient’s History

• Including unhealthy conditions or risky heath habits such as:– scalp lice– smoking– failure to take prescribed

medication, etc.

Subject & ObjectiveSubject & Objective

• See

• Hear

• Feel

• “Think”

Changes in Health StatusChanges in Health Status

• Your actions

• Clients response

• Client outcomes

Client OutcomesClient Outcomes

• Expected

• Deviations

Expectation: Pain ScaleExpectation: Pain Scale

Documentation of AssessmentDocumentation of Assessment

Actual ResponseActual Response

Evaluations

• Verbal

• Non-verbal

Your SignatureYour Signature

• Full name

• Credentials

• Job title

• Initials

Shelia Duncan RN,

CCRN - SD

ICU

Educator

A Little More than The BasicsA Little More than The Basics

• Client/Family Education/Instructions

• Referrals to Community Resources

• Authorizations and Consents

• Plans for Follow-up

• Discharge Plan

• Telephone Calls: Be Specific

Client EducationClient Education

• Family

• Significant Other

Standard EducationStandard Education

Referrals & ConsentsReferrals & Consents

• Standard Consent Forms

• Referrals: Client Specific

• Facility Resources

• Community Resources

SBARSBAR

• S – Situation

• B – Background

• A – Assessment

• R - Recommendation

Phone CallsPhone Calls

• Phone Record

• Phone Orders

• Pager Response

• Documentation

• Facility Policy

Client CallClient CallOffice Scenario Office Scenario

Date and time of callCaller's name and addressCaller's request or chief complaintAdvice you gaveProtocol you followed (if any)Other caregivers you notifiedYour name

Client CallClient CallHospital Scenario Hospital Scenario

Date and time of callPhysician’s nameClient’s chief complaintInformation your providedProtocol you followed (SBAR)Order’s received / not received

““Read Back” Read Back”

 Date and time of call Physician's name and "T/O" to indicate order Verbal order, written word-for-word Documentation that you've read back the order,

to be sure you heard it correctlyDocumentation that you've transcribed it

according to your facility's policyYour name

Faxes & Computerized RecordsFaxes & Computerized Records

• Facts on Faxing Records

• Computer Charting

Safeguards for FaxingSafeguards for Faxing

 1. Check the number before you dial.

 2. Check the number on the fax machine display.

 3. Re-check the number before you press the “send” button.

Computerized DocumentationComputerized Documentation

• Easier form of communication

• Legible

• As legal as when you manually chart

Guide to Guide to Computer DocumentationComputer Documentation

• Double-check entries

• Password security

• Do NOT share your code!

Guide to Guide to Computer DocumentationComputer Documentation

• “HIPPA” computer display

• Log off

• Printouts

• P&P for computer entry errors

• Backup files– Galactica?

Guide to Guide to Computer DocumentationComputer Documentation

Patient data, Confidentiality, and DisclosurePatient data, Confidentiality, and Disclosure

• state's rules and regulations

• facility's policies and procedures

• permanent part of the medical record

Guide to Guide to Computer DocumentationComputer Documentation

Good computerized documentation not only can help you in court, but it can also keep you out of court in the first place.

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

RN * LPN * CNA RN * LPN * CNA Differences Differences

• RN – Nursing process

• CNAs & LPNs – Flow charts & check lists

WHEN THE WHEN THE LICENSED NURSE LICENSED NURSE DELEGATESDELEGATES PATIENT CARE PATIENT CARE

ACTIVITIES TO UAPsACTIVITIES TO UAPs

WHEN THE WHEN THE PHYSICIAN DELEGATESPHYSICIAN DELEGATES

PATIENT CARE ACTIVITIES TO UAPsPATIENT CARE ACTIVITIES TO UAPs

RNRN

• Care Plan

• Standardized Care Plan

• Clinical Pathway

Standardized Nursing Care PlanStandardized Nursing Care Plan

• FormattedFormatted - the nurse checks off care provided.

• The Nurse IndividualizesIndividualizes the care plan specific to each patient

Clinical Care PathClinical Care Path

– Nursing actions for a specific medical diagnosis.

– Specifies daily care required • including but not limited to:

– diet, medications, activity, treatments

– The goal: progress to discharge

KardexKardex

• Card systemCard system - readily accessible to all members of the health care team

• Quick reference Quick reference

Computerized KardexComputerized Kardex

Nurses NotesNurses Notes

• Narrative • SOAP• SOAPIE• SOAPIER• APIE• PIE

• Graphic Charting• Focused Charting• Charting by

Exception

Nurses NotesNurses NotesNarrativeNarrative

• Narrative– Chronological– Legibility– Format

Universal Guideline for ChartingUniversal Guideline for Charting“Nursing Process”“Nursing Process”

Four phases of nursing care:

AssessmentPlanningImplementationEvaluation

Documentation AuditsDocumentation Audits

• Random Audits

• Quality / Performance Initiatives

How to prove MalpracticeHow to prove Malpractice

• Improper or negligent treatment of a patient, as by a physician, resulting in injury, damage, or loss.

• Improper or unethical conduct by the holder of a professional or official position.

• The act or an instance of improper practice.

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

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

Documentation – The wrong way!Documentation – The wrong way!

• Legal situations

Ketchum vs. Overlake Hospital Medical CenterKetchum vs. Overlake Hospital Medical Center

1991 1991

Ms. Ketchum sued Overlake Hospital, contending that her severe mental retardation was caused by what she felt was negligent nursing care.

Expert Nurse WitnessExpert Nurse WitnessProsecutionProsecution

• Assessment

• Documentation

• Report Changes

Expert Nurse WitnessExpert Nurse WitnessDefenseDefense

• Assessment

• Documentation

• Report Changes

Pivotal IssuePivotal Issue

• Documentation

Jarvis vs. St. Charles Medical CenterJarvis vs. St. Charles Medical Center

1986 1986

Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which was subsequently surgically reduced

Pivotal IssuesPivotal Issues

• Reporting Problems

• Following Orders

Inconsistent Nurses NotesInconsistent Nurses Notes

• Standard of Nursing Care

This case truly epitomizes the old saying that if the care was not documented, then it was not done

It was as though a nurse never checked the client during that time period.

Ard vs. East Jefferson General HospitalArd vs. East Jefferson General Hospital

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).

Nurse AvailabilityNurse AvailabilityCall BellCall Bell

• Standard Practice

Wrongful DeathWrongful Death

• The basis for a lawsuit, which is filed due to a death caused by the negligence of another person

Nurse ExpertNurse Expert

• Breach in Standard of Care

• Failure to address high risk problem

• Failure to complete full assessment

Medical ExpertMedical Expert

• Change the Outcome

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

Professional Liability CoverageProfessional Liability Coverage

Does having my own individual professional liability insurance policy make me a more likely target for a lawsuit?

http://www.nso.com/customer/faq_cov.php

Professional Liability CoverageProfessional Liability Coverage

Why do I need an individual professional liability policy?

Won't my employer's insurance coverage protect me?

Case StudyCase Study“Mock Trial”“Mock Trial”

• Judge & Jury

ExamplesExamples

• SOB / Difficulty Breathing

• Chest Pain

• Low BP / Change in LOC

• Lungs “wet” – IVF wide open

ReferencesReferences

1. Ashley, Ruthe C. “Legal Counsel.” Critical Care Nurse, Dec 2004

2. Charting Made Incredibly Easy. 2nd Edition. Lippincott Williams & Wilkins: Philadelphia, Pennsylvania, 2002

3. Feutz-Harter, Sheryl. “Nursing Case Law Update: Faulty Documentation.” Journal of Nursing Law, Vol.2 Issue

4. Mary E. O’Keefe, Nursing Practice and the Law (Philadelphia: F.A. Davis Company, 2001), 140–41.5. Medi-Smart Nursing Education Resources: “Nursing Legal

Issues” http://www.medi-smart.com/documentation.htm6. North Carolina Board of Nursing: http://www.ncbon.com/ 7. Nurses Service Organization: www.nso.com