1 DOCUMENTATION As a Loss Prevention Technique For Advanced Practice Nurses.

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DOCUMENTATIONAs a Loss Prevention Technique

For Advanced Practice Nurses

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Today’s Objectives

Increase awareness of documentation risks, specifically targeting exposure to negligence and malpractice claims.

Enhance the quality of documentation by expanding awareness in order to provide quality patient care and avoid malpractice incidents.

To address the documentation steps in order to protect your patient from harm and minimize your liability exposure.

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Legal Perspective on Documentation

Not documented, not done.

Poorly documented, poorly done.

Incorrectly documented, fraudulent.

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Quality Documentation Reflects Quality Care

Structured documentation typically inspires structured performance.

Document the Nursing Process:

Assessment

Diagnosis

Planning

Implementation

Evaluation

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You Are Judged By How You Document

A well-documented patient care record: Protects your patient Demonstrates that you are a competent nurse to:

– Board of Nursing– Medicare– Other stakeholders and third parties

Minimizes the potential of being named as a defendant in a lawsuit

Greatly assists with your defense if you are named in a lawsuit

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A well-documented patient care record: Minimizes the potential of a court appearance if

you ARE named in a suit

Aids in development of successful defense

Helps against licensure actions

Reduces the chance of criminal charges

You Are Judged By How You Document (continued)

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The Patient Care Record Is a Legal Document

Under state laws, the patient care record is the property of the health care provider

A patient is entitled to request and receive a copy of the record under the laws of most states

The record must reflect accurate and timely information

The patient care record documents the care provided.

You may not alter, remove, copy, or destroy a medical record

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Additions and Corrections: Handwritten Documentation

If you must make a late addition or correction to a patient’s care record, follow these guidelines or your healthcare facility’s protocol:– Mark with one line through the item

– Make the notation / correction and explain why you did so

– Date and sign the corrected documentation

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Additions and Corrections:Electronic Documentation

Obtain assistance from EMR experts in establishing policies and procedures

Establish polices and procedures for standardized action for additions and/or clarifications in EMR

Educate staff to approved EMR policies and procedures

Regularly audit EMRs for compliance with policies and procedures

Remind staff that all entries are automatically dated and timed to prevent contradictory dates and times

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Basis for Reimbursement

Your documentation will influence how you and your employer are reimbursed for services rendered and may minimize financial loss.

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Billing

Include the following documentation to support appropriate billing for services rendered:

the actual provider

the service or services provided and

the diagnosis

These facts should already be in the patient’s care

record.

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Billing and Reimbursement The billing and reimbursement of your facility is your

responsibility, and you should take ownership for the entire process

Be familiar with your health plan participation contracts, and review any changes and additions on a periodic basis

Internally audit your facility’s documentation to determine if documentation consistently supports the code billed

Monthly, monitor a sample of your collections against your charges

Validate that documentation has supported the appropriate coding and billing by monitoring collections

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Medicare Fraud and Abuse

It is Illegal to:

Submit bills for services not rendered

Upcode a service

Unbundle services

Solicit, offer, or receive a bribe or kickback

Bill “non-covered” services as covered services

Fail to comply with Medicare marketing rules

Medicare Fraud and Abuse. Medicare Learning Network. CMS. February 2010

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Medicare Fraud and Abuse

Know and understand:

Anti-Kickback Statute

Physician Self-Referral Prohibition Statute

Medicare Fraud and Abuse. Medicare Learning Network. CMS. February 2010

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Medicare Fraud and Abuse Avoid a Lawsuit

Stay current with CMS billing rules, and follow them consistently

Be aware of common conditions that lead to malpractice claims

Understand your facility’s billing and reimbursement system

Avoid common prescribing errors

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Considerations for Quality Documentation

Do Enter: Contemporaneous documentation

Accurate documentation

Do Not Enter: Fraudulent documentation

Inappropriate documentation

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Documentation Dos

Check that you have the correct medical record before you begin writing.

Make sure your documentation reflects the clinical decision making process.

Write legibly if using handwritten documentation. Contemporaneously record patient care at the time you provide it. Record the time you gave a medication, the dose, administration

route, and the patient's response. Record precautions or preventive measures used, such as placing

the call-bell in the patient’s reach. Document often enough to tell the whole story.

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Documentation Dos (continued) Record each phone call to a physician or other member of the

patient’s treatment team, including the exact time, message, and response.

Record a patient's refusal to allow a treatment or take a medication, obtain the patient’s written refusal, and be sure to report this to your manager and the patient's physician. Document that the patient was informed of the risks of refusing treatment.

If you remember an important point after you've completed your documentation, record the information with a notation that it's a "late entry." Include the date and time of the late entry. Late entries should be limited to facts that are essential to the patient’s care and treatment.

Document review of systems and relevant findings.

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Documentation Dos (continued) Include differential diagnosis

Example:• “c/o epigastric pain for 3 months, differential diagnosis includes but not limited to gastritis, peptic ulcer disease, pancreatitis, and cholecystitis”

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Documentation Don’ts Don't Record a symptom, such as "c/o pain," without also

recording what you did about it Don't alter a patient's record--this is a criminal offense Don't use shorthand or abbreviations unless they are included in

the organization’s approved abbreviation list. Don't write imprecise descriptions, such as "bed soaked" or "a

large amount" Don't give excuses, such as "Medication not given because not

available" Don't record what someone else said, heard, felt, or smelled

unless the information is critical Don't record care ahead of time--something may happen and

you may be unable to actually give the care you've recorded

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10 Documentation Strategies1. Do not erase, use “white out”, or cross out an error

with more than one line2. Record only the patient’s statements, clinical facts,

observed behavior, and health services rendered3. Do not criticize other health care providers or

document your personal opinions4. Begin each entry with the date and time and end

each entry with signature and title

Example: (03/31/09 - 7:50AM - Jane Doe, BCCNS)

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5. Do not leave blank spaces

6. Record all entries legibly and in ink

7. Avoid generalized phrases such as "bed soaked" or "a large amount"

8. If an order is questioned, document that clarification was sought, the order discussed and resulting resolution

10 Documentation Strategies

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9. Document only your own observations and patient services rendered.

10. Do not permit any visiting relative or other third-party access to the patient care record unless they have been granted legal authority to do so.

10 Documentation Strategies

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Communication Challenges

Attributes: Factual

Accurate

Current

Confidential

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Reporting Challenges

APNs must communicate information about patients to nurses and other members of the patient’s health care team.

Oral report, video or audio taping

Documentation / written report

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Documentation Techniques

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Documentation TechniquesSOAP

S: Subjective

O: Objective

A: Assessment

P: Plan of Care

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SOAP

Strengths Address specific problems

Organized

Problem List

Notes show continuity of care and evaluation and resolution of problems

Eliminates nonessential data

Weaknesses Can be inflexible

Routine care can be difficult to document

Time-consuming

Difficult to decide where to place data

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SOAP (SOOOAAP) Expanded method that includes additional

risk-reduction techniques

Opinion, Options, Advice, Agreed Plan


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Narrative Chronological account of events in a

free-form, sentence-based structure

May include columns or sections to organize information


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Narrative

Strengths Simplified method

Control

Chronological

Adaptable

Easy to teach or learn

Weaknesses Lack of guidance

Freeform can produce notes that are:

– Fragmented

– Rambling

– Inconsistent between authors

– Non-informative

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Electronic Documentation Increasingly common

Use of technology to manage patient medical records

Variety of hardware and formats

Allow patient medical records to be created, updated, stored, and retrieved via computer


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Electronic DocumentationStrengths Legible

Prompting

Changes tracked

Modifiable system

Consistent

Easy to find

Entries are time and date stamped

Weaknesses Facility must make major

cash investment

Training

Possibility of software or hardware crash

Major psychological change

Inaccuracies

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Open Charting Also referred to as “Shared

Medical Records

Currently employed by a number of hospitals

Method devised to encourage a patient to be involved in his or her own care, to review the notes made by their healthcare providers


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Open ChartingStrengths Encourages patients to review their

own patient care record Promotes meticulous documentation

by healthcare providers Fosters patient inclusion in the

healthcare delivery process

Weaknesses Requires significant time May raise patient queries regarding the

healthcare delivered

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HIPAA and Documentation

Security Rule and Privacy Rule

The Security Rule Documentation standard has three implementation specifications.

– Time Limit (Required)

– Availability (Required)

– Updates (Required)

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HIPAA and Documentation

HIPAA requires covered entities to meet documentation requirements

Be aware of and report any suspected security breaches

Take steps to prevent patient health information from falling into the wrong hands or being inadvertently altered or destroyed

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Effective Risk Management Strategies

Know and comply with State Scope of Practice Comply with Nurse Practice Act Practice Competent Nursing Comply with policies, procedures and regulatory

requirements Practice appropriate billing and coding methods Seek additional educational opportunities Follow ICD-9 CMS guidelines for documentation Follow appropriate incident reporting protocol

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Incident Reporting

Losses can be reduced by a timely, prudent, and compassionate response to an incident.

Report any incident to your risk manager. Report an incident to your insurance provider – if

you have your own policy.

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Learn Your Organization’s Guidelines

– Treatment-related injuries– Missed/incorrect diagnosis– Employee exposures– Facility-acquired pressure sores

– Patient falls– Medication errors– Equipment failure– Complaint by patient, family,

visitor

Examples of Reportable Incidents

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BE ALERT! Report Unusual Occurrences

Document ONLY the facts Report immediately, i.e., within 24 hours

Do not speculate

Do not draw conclusions

Do not document impressions

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Quality Monitoring

Participate in investigations and analysis of the cause of the incident

Maintain confidentiality of all information

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Case StudyFailure to Assess Patient – 78 year old female

Patient– 78 year-old female nursing

home resident

– Hypertension, chronic anemia, chronic renal failure, congestive heart failure, morbid obesity

– She was on the anit-coagulant Coumadin because of atrial fibrillation

Defendant– Onsite NP working for outside

healthcare facility via contract with nursing home

– Responsible to answer calls for healthcare facility and return emergent pager calls

– Responsible for making visits to nursing facility as needed

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Case StudyFailure to Assess Resident – 78 year old female

Day 1– Attending MD (also president of the facility) ordered that the

resident be started on Bactrim for bladder infection– Staff questioned order because of potential for adverse effect of

combining Bactrim and Coumadin– Resident also took daily doses of ibuprofin

Day 2– Lab tests showed no bladder infection– Bactrim was not discontinued

Day 6– Lab tests showed that resident’s bleeding time had increased – at

risk of bleeding from Coumadin

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Day 8– Resident bleeding from gastrointestinal tract

– NP gave orders to stop Coumadin for 2 days and recheck blood tests on Day 11

Day 10– Alleged that the NP was advised by nursing home staff of blood clots

in resident’s stool

– NP faxed her on-call report to the medical director after each call from the nursing home

– NP did not keep copies of the reports or of her notes made during calls

– Medical director denied receiving the reports

Case StudyFailure to Assess Resident - 78 year old female

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Days 9-11– Resident continued to bleed

– NP, attending and medical director were notified but took no action

– Nursing staff notes reflect that the resident was dizzy and nauseated

Day 11

– Resident found dead in bed

– Bled to death from gastrointestinal hemorrhage

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Allegations Against NP– Failure to evaluate, monitor, and treat the resident’s

severe anemia and bleeding

– Failure to timely contact the medical director about the patient’s bleeding

– Exceeding the scope of practice by making medical decisions about the patient’s bleeding

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The Defense Argument– NP was within the standard of

care for taking a telephone triage call by holding the Coumadin and ordering a follow-up INR lab level.

The Plaintiff Argument– NP should have obtained vital

signs, medications, current problem list, past medical history and labs.

– Responsibility of the NP to obtain the information she needed to make an appropriate assessment and not wait for it to be offered to her.

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The Resolution– Took 2 ½ Years to settle

– Settled at mediation for $450,000 plus additional $181,225 in legal expenses

– Healthcare facility and nursing home also settled for separate amounts.

Total incurred expense for NP: $631,225

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Risk Management Comments– Unclear accountability and communication channels

– Nursing concerns were not heeded

– Role of pharmacist is unclear

– Defendant did not document her actions

– Defendant did not physically assess the resident despite evidence of acute G.I. bleed

– Oversight of the resident was not maintained by any individual practitioner

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Risk Management Recommendations– Clearly define role of scope of practice of APN

– All communication is to be documented in a pre-defined, consistent, confidential manner

– Each resident must have an identified attending physician

– On-call practitioners must physically asses deteriorating resident when physician unavailable

– Do not fax information without providing original documentation in the resident’s health record

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Documentation Examples

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Documentation: An Example

– Abdominal pain listed on problem list 1/2010, related to acute gastroenteritis-resolved

– Patient admitted to hospital 4/2010 for abdominal pain, radiologic evaluation performed- CT abdomen shows abdominal aortic aneurysm

– The problem list still maintains the problem abdominal pain from 1/2010. Could appear abdominal pain was actually from AAA in 1/2010

Could be perceived as delay in diagnosis

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Sample Medical RecordDate: May 7, 2010Patient Name: Tom JonesChief Complaint: C/o 2 day history of rectal bleeding.

HPI: 56 yr old male c/o rct bleeding for 2 days. States he feels fine. (+) family hx colon cancer.

Active Problems Mild-Moderate Abdominal Pain (789.00)Family history of Diabetes Mellitus (V18.0)Family history of Essential HypertensionHypertension 25 Jan 2008 (401.9)Hypothyroidism (244.9)Mammogram Screening; Bilateral (V76.12)PMH Arthritis (V13.4)Asthma (493.90)No Birth History; Term BW, 7-10, C/S, jd, photorxDiabetic Autonomic Neuropathy Type I (250.61)No Exercising RegularlyHypertension (401.9)Red Blood In Bowel Movement (Hematochezia) Resolved (578.1)Reported Prior Thyroid Disease.eg

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PSH Bone Grafting With Microvascular Anastomosis Iliac CrestColonoscopy (Fiberoptic); 2005-tics, ih, polp-3 yrsHysterectomy (V45.77)No SurgerySurgery Of Male Genitalia Vasectomy (V25.2)Tonsillectomy.eg

Current Meds Prilosec 10 MG Capsule Delayed Release;TAKE 1 CAPSULE DAILY; RPTKlonopin 2 MG Tablet;TAKE 1 TABLET TWICE DAILY AS NEEDED.; RPTCombiPatch 0.05-0.14 MG/DAY Patch Biweekly;; RPTStaticin SOLN;APPLY AS DIRECTED.; RPTStatins Support MISC;TAKE KIT; RPTStatins Depletion MISC;TAKE KIT; RPT.eg

Allergies Aleve TABSPenicillin G Pot in Dextrose SOLNSulfa Drugs.eg

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Family Hx No Family history of Coronary Artery DiseaseFamily history of Diabetes MellitusNo Family history of Essential HypertensionFamily history of Family Health StatusFamily history of Family Health Status Brother 1; 0Family history of Family Health Status Brother 1; x2x1-deceased car accidentx2

healthyFamily history of Family Health Status Father; deceased colon cancerFamily history of Family Health Status Number Of Children; 2 boys twinsNo Family history of Family Health Status Of Mother - AliveFamily history of Family Health Status Sister 1; x3Family history of Family Health Status Sister 1Family history of Hyperlipidemia; FatherFamily history of HypertensionFamily history of Reported Family History Ischemic Heart Disease Before Age 50No Family history of Malignant Carcinoma Of The Breast; motherNo Family history of Malignant Neoplasm Of The Large IntestineNo Family history of Reported A Family History Of AlcoholismNo Family history of Reported A Family History Of Congenital Heart DiseaseFamily history of Reported Family History Ischemic Heart Disease Before Age 50No Family history of Thyroid Disorder

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Personal Hx Alcohol; OccasionallyNo Behavioral HistoryBeing A Social DrinkerCaffeine UseCigars (___ A Day) (V15.82)Currently In SchoolDaily Coffee Consumption (___ Cups/Day); 3 cups dailyDaily Cola Consumption (___ Cans/Day); 1 dailyNo Daily Tea Consumption (___ Cups/Day)Drinking In Moderation (2 Drinks / Day Or Fewer)No Drug UseExercise HabitsNo Exercising RegularlyMarital History - Currently Married

Never SmokedOccupation:; Self employedNo Secondhand Tobacco Smoke In HomeNo Smoking CigarettesNo Smoking Cigarettes For ____ Pack-yearssocial history reviewed; lives w/ mom, dad, 2 yr old brother joe, 1 dog , no

smokersNo Tobacco Use

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Physical Exam Abdomen:Visual Inspection: ° Abdomen was normal on visual inspection.

Auscultation: ° Bowel sounds were normal.

Palpation: ° Abdomen was soft. ° No abdominal tenderness.

° No mass was palpated in the abdomen.

Hepatic Findings: ° Liver was normal to palpation.

Splenic Findings: ° Spleen was normal to palpation.eg

Plan Notify office if symptoms worsen.

Electronic Signature: Sue Smith, NP Date: May 14, 2010 20:00

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Inadequate Documentation1. HPI is not complete. Documentation contains

abbreviation which is not approved: rct

2. Family History: Contradiction- states there is a family history of colon cancer with father –next line below states no family history

3. Plan: Omits quality of signs and symptoms follow-up and follow-up instructions to seek emergency care if it is during a weekend

4. PE: Omits rectal exam

5. Time stamp of electronic signature is 1 week after original date of service

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Additional Resources

CMS Website (cms.gov)

Office of Inspector General (2010 Work Summary) (oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf)

ICD-9 (cdc.gov/nchs/icd.htm)

The American Association of Nurse Attorneys (TAANA) (taana.org)

California Health Advocates (cahealthadvocates.org)

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Documentation Bloopers “The patient refused an autopsy.” “The patient has no previous history of

suicides.” “Patient has left white blood cells at

another hospital.” “On the second day, the knee was

better, and on the third day it disappeared.”

“The patient has been depressed since she began seeing me in 1993.”

“Discharge status: Alive but without permission.”

“Healthy appearing decrepit 69-year old male, mentally alert but forgetful.”

“Patient has two teenage children, but no other abnormalities.”

“Patient had waffles for breakfast and anorexia for lunch.”

“She is numb from her toes down.” “While in ER, she was examined, x-

rated, and sent home.” “The skin was moist and dry.” “Patient was alert and

unresponsive.” “Rectal examination revealed a

normal size thyroid.” “She stated that she had been

constipated for most of her life, until she got a divorce.”

“Skin: somewhat pale but present.”

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To the extent this presentation contains any examples, please note that they are for illustrative purposes only and any similarity to actual individuals, entities, places or situations is unintentional and purely coincidental. In addition, any examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice. Use of the term "partnership" and/or "partner" should not be construed to represent a legally binding partnership. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2010 CNA. All rights reserved.

1 DOCUMENTATION As a Loss Prevention Technique For Advanced Practice Nurses.

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Transcript of 1 DOCUMENTATION As a Loss Prevention Technique For Advanced Practice Nurses.