The quality of nursing documentation is an important issue for both patients and nurses.  Obviously quality nursing documentation enhances patient care as this leads to better communication of the issues. “No matter how skilled or experienced you are, inaccurate or incomplete nursing documentation can mean serious trouble for your patients—and for you if you’re ever involved in a lawsuit.”[i]

Nursing documentation includes everything involved in the patient’s care:  admission history, care plan, progress notes, nursing notes, assessment forms, vital signs, any special flow sheets such as neuro check sheets, restraint forms, code sheets, discharge forms, MAR’s (medication administration reports), etc.  Documentation in nursing is critical to determine if the standard of care was met in taking care of a patient.  When something is not documented not only in legal terms can it be said that it was not done but those that follow the nurse have no way of determining what was done.  Examples would be if a med was given but not charted a nurse that follows may assume the med was missed and give it; thus the patient would receive two doses of the medication which in some instances could have negative consequences.  Admission history being done and the nurse not adequately doing a Fall Risk assessment can have dire consequences if the patient should have been placed on Fall Precautions and this was missed.  The nurse not noting a change on the assessment but does bring it to the attention of the physician verbally (also does not chart that they called the physician).  18 months later at trial the nurse is asked why they did not realize that the condition of the patient changed, or why they did not notify the physician.  Even if they remember the situation, it is not charted so it basically cannot be proven as having been done.

Document at the same time as your assessment and/or treatment. Make sure to date, time, and authenticate each entry with your signature and professional credentials as close as possible to the time you performed an assessment or intervention. Any lag in documentation undermines patient safety. Here’s an example: Let’s say you just gave your patient pain medication and the charge nurse tells you to take your lunch break. You ask a colleague to monitor your patient while you’re on break. You advise her that the patient is stable, but you leave without documenting your administration of the medication. While you’re at lunch, the patient asks your colleague for something for the pain. Checking the EMR, your colleague sees no documentation of the drug dose you administered before leaving and administers an additional dose of opioid. This error could have been avoided had you documented the pain medication administration and informed your colleague.[ii]

When reviewing the medical record, the plaintiff’s attorney looks for facts to prove each of the four elements of the case (duty, breach of duty, causation, and damages).   Here are some of the documentation mistakes that are sure to catch an attorney’s attention:

  * notes that are sloppy, incomplete, inconsistent, illegible, or have gaps. These reflect poorly on the     nurse and undermine the nurse’s credibility in front of a jury.

* entries that aren’t timed or dated or that appear out of sequence

* entries that indicate delays or failures in initiating treatment orders

* entries that show the care provided was substandard or inappropriate

* entries that show care rendered that wasn’t supported by a healthcare provider’s prescription

* unexplained late entries

* erased or obliterated entries

* lack of documentation of patient education or discharge instructions

* entries made with different ink or pen (if the record is handwritten)

* the statement “Completed an Event Report,” which can serve as a red flag that something went wrong during the patient’s care.[iii]

 

Some of pitfalls in documentation have been eliminated by the introduction of EMR (electronic medical records) but not all institutions have fully integrated these types of systems yet and the EMR systems have come with their own set of problems.

• Do you want to sharpen your skills in understanding the intricacies of electronic medical records (EMRs)?
• Are you an attorney who needs to probe the details of an EMR but doesn’t know what information is hidden?
• Do you need to analyze the information in reams of printed EMRs?

 

Join Dr. Carlson and Pat Iyer for an informative webinar on April 24, 2013: Electronic Medical Records: How to Navigate Your Way Through the Paper Printouts. This is a live program with an opportunity for you to get your questions answered by Dr. Carlson. Order the digital download if you cannot join us that night.

Go to www.patiyer.com/aaa to register!

 

When I was still working at the bedside and would orient nurses I was a stickler about documentation.  When auditing the charts for my unit I would find the following type of errors:  incomplete admission histories, incomplete assessments (nurses for some reason have an issue with checking pupils; they either leave it blank, do not put in the size of the pupils, or unfortunately sometimes they obviously “make it up”—if you are charting PERRL and the patient has only one eye you obviously did not check the pupils).

 

The following is from a case a recently reviewed.  The patient was admitted a fall and short term loss of consciousness.  The patient had Q2H neuro checks ordered.  In reviewing the chart first of all I found that there was no documentation that this was done every 2 hours; secondly most of the time the part of the exam involving the pupils was not even addressed and if it was they did not always mark the size of the pupils.  This patient also had significant ongoing nausea and vomiting that was not reported to the physician.  The outcome for this patient was unfortunate and the above two areas were items that I pointed out to my client attorney.  Were the neuro checks done and not charted?  What matters is that there is no documentation and this patient had a less than positive outcome.

 

Your patient’s medical record serves several purposes.

* It’s a legal document required by law and other regulatory bodies.

* It’s a communication vehicle for healthcare providers that tells the patient’s story while he or she received care at a facility.

* It’s often used for implementing quality improvement initiatives.

* It’s used for utilization review to help determine appropriate level of care for admission and to obtain reimbursement.

* It’s used for research and education.

* It’s the most credible evidence in legal proceedings on whether the care given to the patient met the legal standard of care.[iv]