Workload and Legal Issues Related to Nursing Documentation

October 30, 2018 1

Why is documentation important? Nursing documentation provides an accurate, clear and

comprehensive picture of the patient’s needs, nurse’s interventions and the patient’s outcomes.

Failure to include the above in the documentation may put the patient’s health at risk as patient records are used to communicate client information and ensure continuity of care.

Nurses are also expected to report medication errors, near misses and adverse reactions in a timely manner.

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Documentation ↔ Quality of Patient Care

00.20.40.60.8

11.21.41.61.8

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a b c d

Quality of Nursing Documentation affects the Quality of Patient Care

Quality of Patient Care Quality of Nursing Documentation

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Documentation

Legislation and Standards of Practice requires nurses to document the care they provide to demonstrate accountability for their actions and decisions.

Nurses are accountable to _______ to document.• Patients and families• The CNO• Colleagues• Employers• The Public

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Minimum Requirements

Should be a complete record of nursing process and care.• Assessment, Planning, Intervention and Evaluation.

Provide clear, current, relevant and individualized plan of care to meet client’s needs and wishes.

Accurate, timely and complete.

Captured in a permanent record.

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Methods of Nursing Documentation

What do you use at your organization?

• Paper-based.

• Electronic.

• Mixed.

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Paper-Based

Advantages

• Cost.

• Familiarity.

• Easily customizable to meet needs.

Disadvantages

• Time consuming.

• Lack of structure.

• Storage.

• Accessibility.

• Illegibility.

• Timeliness of care.

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ElectronicAdvantages

• Integrated patient information.• Immediately available

information.• Legible.• Clear.• Real-time charting.• Decreased chance of error from

misinterpreted orders, etc.• Less time-consuming for those

with computer skills.

Disadvantages

• Costly.• Full application is limited.• High degree of variability in

functionality and user-friendliness.• Reduces face-to-face communication

with other health-care providers → less understanding of care plan.

• Increased chance of error or overlooking info from “clicking.”

• Time-consuming for those without computer skills.

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How do they compare?Paper Documentation Electronic Documentation

Process xStructure xAdherence to standards xAdherence to best practices xAbility to capture nursing data xLegibility XAccessibility xCost XUser-friendliness XAbility to produce comprehensive reports i.e. discharge notes X

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Mixed MethodsDuplication.

Increased responsibility.

Increased workload.

Greater chance of incomplete documentation → errors.

Difficulty finding information.

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Workload IssuesStudy by Zamanzadeh et. al. (2015) reported:

“…the number of patients, the number of nurses and having sufficient knowledge of the nursing process are the most important factors affecting nursing documentation.”

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Workload IssuesRegardless of the method(s) of nursing documentation used, the burden

has increased over time related to:

• Funding cuts.

• Understaffing.

• Increased patient census.

• Increased nurse:patient ratios.

• Increased patient complexity and acuity.

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• Added safety processes i.e. documentation of double-checks.

• Increased use of technology.

• Nursing fatigue.

• Additional requirements to capture data used for organizational and funding decisions, accreditation, etc.

Workload Issues cont’d

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Using Nursing Notes Outside of the Hospital

Arbitrations.

Regulatory colleges (e.g. College of Nurses).

Coroner’s inquests.

Civil litigation.

Criminal litigation.

Other.

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College of Nurses of Ontario

During an investigation or an inquiry, an investigator will request all relevant clinical notes and records regarding the care of the patient.

There is no limitation on the timeframe for someone to make a complaint or report to the College.

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Documentation in Litigation Ares v. Venner (Supreme Court of Canada, 1970)

• Nurses’ notes are admissible as prima facie proof of the truth of the facts and events that they recorded.

• Three conditions must be satisfied. The notes must be made: All at once.By someone having knowledge of what’s being recorded; andBy someone under a duty of care to make the entry or record.

• If these conditions are satisfied, the notes will be considered true unless the party challenging its accuracy can persuade the court otherwise.

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Documentation in Litigation cont’d

Joseph Brant Memorial Hospital v. Koziol (Supreme Court of Canada, 1978)

Where there was an absence of entries in the nursing notes, the Court inferred that “nothing was charted because nothing was done.”

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Documentation in Litigation cont’d

Ferguson v. Hamilton (Ont. High Court of Justice, 1985)

• The Court concluded that the fact that there was nothing in the nurses’ notes during a period of time did not necessarily mean that nothing was done, provided:

There was evidence to the contrary, and

The usual practice was not to chart.

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Charting by Exception Charting by exception involves the practice of making no

clinical notes unless something abnormal is noted.

Neither the courts nor the College of Nurses has rejected charting by exception nor advised against its use.

Charting by exception has raised questions about what assessments/interventions were done.

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Charting by Exception Re Leroux, CNO Discipline Committee

“…any reasonable nurse would have documented even the most incidental physical contact with the patient regardless of hospital policy. The member did not…[T]he member was specifically advised by [Nurse B] to document because an “exceptional circumstance” had occurred in that the patient had accused him of sexually assaulting the patient. If that doesn’t represent an exception that should be charted, then the panel is uncertain what would.”

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Late Entries

Consult your workplace policies regarding late entries.

Late entries must be clearly marked as a late entry. For example:

October 1, 2018 [Late entry of September 10, 2018]

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Late Entries cont’d

CNO Disciplinary Decision, Unnamed (November 2, 1995)

• 1630 = [physician #2] paged; [physician #1] notified about restlessness, cold clammy perspiration on forehead. Abdominal pain. “Feeling poorly”.

• 1645 = unable to obtain BP + pt is uncooperative. Unable to draw blood for x-match + hemo

• 1650 = seen by [physician #1] + taken to PAR

CNO Disciplinary Decision, Wright

• [Date] Resident was having a seizure like activity. He had finished eating an egg sandwich for snack. His blood sugar was 6.2 before snack. Half an hour later the seizure like activity started. His skin was diaphoretic. BP 180/60. P82. Now blood sugar was 1.2. Insulin given as ordered at HS and he had a cool drink. Felt better after a few minutes. Skin warm and dry.

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Professional MisconductIt is professional misconduct if you:

Fail to keep records.

Falsify a record.

Sign or issue a false or misleading statement.

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Conclusion

It is important to have accurate and complete documentation.

There are many examples when you may need to look atyour documentation at a later date.

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Workload and Legal Issues Related to Nursing Documentation

October 30, 2018

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