documentation

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DocumentationDocumentation

Donna Adelsperger RN, M. Ed.Donna Adelsperger RN, M. Ed.

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Definition of DocumentationDefinition of Documentation

Defined as written evidence of the Defined as written evidence of the interactions between and among health interactions between and among health professionals, patients, and their professionals, patients, and their families; the administration of families; the administration of procedures, treatments, and diagnostic procedures, treatments, and diagnostic tests; the patient’s response to them tests; the patient’s response to them and education of the family support unit.and education of the family support unit.

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Defensive DocumentationDefensive Documentation

Major purpose of the medical record is to Major purpose of the medical record is to document the care given to the patientdocument the care given to the patient

It also is the communication to all members It also is the communication to all members of the health care teamof the health care team

Documents and support continuity of care Documents and support continuity of care from one professional to the anotherfrom one professional to the another

Also a legal documentAlso a legal document

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Defensive Documentation Defensive Documentation

The chart is a very persuasive witness The chart is a very persuasive witness because it is the description of the facts at because it is the description of the facts at the timethe time

There should be no unanswered questions in There should be no unanswered questions in the patient’s record that plaintiff attorneys the patient’s record that plaintiff attorneys can use to construct their version of what can use to construct their version of what happenedhappened

3 recommendations: 3 recommendations: DOCUMENTDOCUMENT- - DOCUMENTDOCUMENT - - DOCUMENTDOCUMENT

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Defensive Documentation Defensive Documentation

(Perinatal) (pediatric)_All nurses should (Perinatal) (pediatric)_All nurses should know that the inadequately documented know that the inadequately documented medical record can be their worse medical record can be their worse liabilityliability

The well-documented medical record The well-documented medical record can be their greatest legal asset can be their greatest legal asset

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Avoid using empty, meaningless Avoid using empty, meaningless charting phrases such as, “physician charting phrases such as, “physician notified of patient’s condition”notified of patient’s condition”

When report given to MD, the nurse When report given to MD, the nurse can expect that person (MD) to can expect that person (MD) to respond in timely fashion.respond in timely fashion.

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When communicating with a charge When communicating with a charge nurse or another nurse recognized as a nurse or another nurse recognized as a resource documentation of discussion resource documentation of discussion seen as consultation and should be seen as consultation and should be documented.documented.

Nurses rarely document this kind of Nurses rarely document this kind of communicationcommunication

Can use chain of command only when Can use chain of command only when there is sufficient timethere is sufficient time

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Documentation-Documentation-Top TipsTop Tips

Don’t squeeze information into the chartDon’t squeeze information into the chart Don’t write between the linesDon’t write between the lines If there is an error, draw a single line If there is an error, draw a single line

through it, date it, initial itthrough it, date it, initial it

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Documentation reflects: character, Documentation reflects: character, competency, and the care delivered competency, and the care delivered by the nurse by the nurse

In a courtroom the medical record In a courtroom the medical record will will represent the nurse, represent the nurse, rather than rather than the nurses’ bedside manner or the nurses’ bedside manner or caring attitudecaring attitude

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Verifies care given & status of the patientVerifies care given & status of the patient Clearly depicts a complete picture of the Clearly depicts a complete picture of the

patientpatient Ensures that quality of care provided is Ensures that quality of care provided is

in accordance with professional nursing in accordance with professional nursing practice standardspractice standards

Must be adequate, legible , timely and Must be adequate, legible , timely and completecomplete

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All of the following can lead to the All of the following can lead to the state licensing board suspending or state licensing board suspending or revoking the nurse’s license:revoking the nurse’s license:• Failure to document entries on Failure to document entries on

patient recordpatient record• Falsification of patient recordsFalsification of patient records• Making incorrect entriesMaking incorrect entries

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Cases come to court a long time Cases come to court a long time (usually) after the events occurred(usually) after the events occurred

Nurses, therefore have little or no Nurses, therefore have little or no recollection of the events recollection of the events surrounding the case and must rely surrounding the case and must rely on their documentation for what on their documentation for what occurredoccurred

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The Duty to DocumentThe Duty to Document

Nurse Practice Acts state the general duty is to Nurse Practice Acts state the general duty is to “record pertinent information including the “record pertinent information including the response to interventions”response to interventions”

While the medical record is “owned” by the While the medical record is “owned” by the institution it is maintained for the benefit of the institution it is maintained for the benefit of the patientpatient

Courts have held that poor documentation Courts have held that poor documentation creates presumption of poor carecreates presumption of poor care

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Intensive Documentation Intensive Documentation RequiredRequired

Sudden decline in patient’s conditionSudden decline in patient’s condition Patient injuries/medication errorsPatient injuries/medication errors Equipment failure/incorrect useEquipment failure/incorrect use Failure of provider to respondFailure of provider to respond The “red flag” patient or familyThe “red flag” patient or family Unresolved disagreements in patient care Unresolved disagreements in patient care

between providersbetween providers

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Factors that Define Quality Factors that Define Quality DocumentationDocumentation

Frequency and completenessFrequency and completeness• must follow the established rules of must follow the established rules of

documentationdocumentation• rules come from federal regulations, state rules come from federal regulations, state

statutes, accreditation boards, policies and statutes, accreditation boards, policies and procedures of the hospital and the standards procedures of the hospital and the standards set by professional organizationsset by professional organizations

The chart must truly reflect that the The chart must truly reflect that the standard of care for patient was metstandard of care for patient was met

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Do Document the FollowingDo Document the Following

Patient behavior. Document Patient behavior. Document descriptiondescription of noncompliant behavior of noncompliant behavior

Use quotations when appropriateUse quotations when appropriate Document neatly and legibly Document neatly and legibly

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Late EntriesLate Entries

Add late entries at first available Add late entries at first available spacespace

Document date and time the event Document date and time the event occurredoccurred

Clearly identify the entry as a late Clearly identify the entry as a late oneone

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Courts have issued a warning to nurses that Courts have issued a warning to nurses that the availability of accurate medical records the availability of accurate medical records is is NOTNOT a a technicalitytechnicality but but IS IS a a legal legal requirementrequirement

According to a Charles Ward, MD, “in a According to a Charles Ward, MD, “in a courtroom the finest care rendered under courtroom the finest care rendered under the best circumstances may be difficult or the best circumstances may be difficult or impossible to defend if it is not impossible to defend if it is not documented”documented”

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Nurses’ communication skills lay the Nurses’ communication skills lay the foundation for the care delivered to the patientfoundation for the care delivered to the patient

Nurses are key members of the health care Nurses are key members of the health care teamteam

Complexity of care is increasing, so complexity Complexity of care is increasing, so complexity of nursing documentation increasesof nursing documentation increases

Perfecting skill of documentation is just as Perfecting skill of documentation is just as important as any other skill used in the clinical important as any other skill used in the clinical settingsetting

documentation

Education

health care team

medical record

care delivered

patients condition

defensive documentation

care

nurses

documented