Nursing Documentation:  Legal Ramifications

My experience as a clinical bedside nurse and a legal nurse consultant has proven to me that many nurses simply do not understand the medical and legal ramifications of poor, incomplete documentation.  Yes, the medical record is a document that, if not properly utilized, can lead to problems for the healthcare provider if a suit is filed in the care of that particular patient; but also there can be significant medical ramifications that occur due to incomplete charting in the medical record.  Nurses are with the patient 24/7 and have the ability to significantly impact the care of any patient.  Good assessment skills and good documentation, on the part of nursing staff, is a very important piece to the communication regarding the care of any patient.

I personally was involved in documentation audits in the last unit that I worked as a bedside nurse.  This unfortunately, was mostly done in advance of Joint Commission visits to the hospital, in order to have the staff get the charting in order.  Nurses took the results of these audits, which were done in an anonymous manner pointing out only the deficient areas and not what patients or staffs were involved, as if they were personal attacks and not an opportunity to learn and improve nursing skills.  Because of this documentation did not improve in this unit.  Examples of areas that were significantly deficient were incomplete assessments, restraint documentation, follow-up on pain medications, documentation of skin issues, and following physician order sets.  All of these areas, if a patient/family files a lawsuit can have significant negative impact for the defendant.

Handoff communications.

Poor handoff communication results in errors, both minor and major, which may result in increased lengths of stay and increased costs. According to The Joint Commission, handoff communication has often been the leading root cause of malpractice lawsuits since the organization began collecting the data in the mid-1990s (Rizzo, 2013).   Handoff communication should include all important issues regarding the care of a patient for the next care giver, whether another nurse, another department of the same institution, or another facility, to facilitate optimal care for the patient

Example of poor handoff communication:  A patient is transferred to the ER from a long term facility.  The patient has cognitive issues and cannot communicate with others in a meaningful manner.  Earlier in the day the patient had a G-tube manipulated in the facility due to the tube malfunctioning.  The patient was sent to the ER for vomiting, fever, and abdominal pain.  The patient was sent to the ER without staff from the facility and no handoff documentation to describe recent events in the care of this patient.  The patient in the ER had an elevated white count and a temperature of 102.  The ER doctor, in documenting differential diagnoses for the patient actually charted that there had been no recent manipulation of the   G-tube and therefore an intestinal rupture was not immediately considered.  The patient was admitted and the next day a CT scan showed a perforation of the stomach wall and the patient was emergently taken to surgery.  Unfortunately her sepsis had progressed and her family eventually withdrew care due to the overwhelming effect the sepsis had on her body systems.  Unfortunately this patient had been taken to the same ER the prior day, with the same lack of handoff communication, and the same symptoms.  The patient was finally admitted with the 3^rd ER visit due to her deteriorating vital signs and obvious signs of sepsis.  The G-tube had been manipulated just prior to the first ER visit.  The reason for the visit was sudden vomiting of emesis untypical of this patient’s usual emesis. (this patient did have a history of vomiting).  The manipulation of the G-tube was never reported to the ER and the patient was sent to the ER in a private ambulance.  This lack off handoff communication was a Breach in the Standard of Care.  (I am sorry for the poor flow of this example.  This was a real case that I have changed the exact tubing and type of care facility but otherwise the events occurred as outlined).

Medication errors: As the rate of comorbidities rise, the average patient today tends to be on more medications at one time than in the last decade, according to Dr. Moffatt-Bruce. This leads to worse potential side effects and more potential challenges for patients once they leave the hospital. Dr. Butler, who sees the same problem at her healthcare system, recommends implementing a comprehensive medication history and reconciliation process during care transitions as well as increased patient education to reduce associated risks (Rizzo, 2013).

Examples of Medication Errors:

A patient goes to the ER with a complaint of neck pain.  He had also fallen the previous day and hit his head.  The patient had a history of aortic valve replacement and was on Coumadin.  While in the ER this patient was given a significant amount of IV Dilaudid for his neck pain and also.  He was also given Toradol 60 mg IV for his pain.  After all of the medications he was very somnulent yet was sent home.  He was found by his wife the next morning unconscious in a bed full of coffee-ground emesis.  The life squad was called and the patient was taken back to the same ER.  Toradol increases bleeding times and patients that are given this medication should be monitored closely.  Since the patient was already on Coumadin this would obviously have increased his risk for bleeding.  He was transferred to a facility that provided higher level of care but in the end he was taken off of life support.  He had suffered a massive head bleed and a GI bleed.  Yes, the physician should probably not have ordered the Toradol since the patient was on Coumadin but also the nurse should have been aware of the interactions of the two medications and approached the physician regarding the safety issues of giving this medication.  There was no documentation that the physician was made aware of the patient’s ongoing somnolence.  On a side note, the patient’s blood pressure was >200/>100 on admission and discharge and this was never addressed in the documentation or with medication.

A nurse gives a patient pain medication but neglects to chart the medication at the time of administration.  30 minutes later the patient complains to another nurse regarding his pain and even though she is not his nurses she goes ahead and gives him pain medication and charts the same.  Who is at fault here?  Obviously the nurse that did not chart giving pain medication was negligent in her charting.  Good communication though would probably have entailed the second nurse approaching the patients’ nurse regarding the patient’s request for pain medication prior to giving the dose.