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    Nurs ingDocumentat ion

    Your License may depend on i t !

    Nelia B. Perez RN, MSN

    PCU - MJCN

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    Taking a Poll

    1. Have you been involved in a patient

    complaint against your institution?2. Do you feel like your documentation

    would support you in a court of law?

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    A patient you cared for 9months ago is unhappy withthe outcome and has filed a

    malpractice lawsuit againstyou.

    Now what?

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    The Court

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    Legal Case Studies

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    Duty of Care

    Based on existence of the nurse-patientrelationship

    A legal status created when the nurse islegally obligated to provide nursing care toa patient

    Law will demand that the nurse perform asa reasonably prudent nurse

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    Breach of Duty

    Nurses care fell below the acceptable

    Standard of CareResults:

    malpractice case compensatory $$$

    loss of nurses license

    loss of job / ability to work

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    Nursing Negligence /

    Malpractice

    Any action by a nurse that falls

    below generally accepted standardsof nursing care, and causes in juryto

    a patient

    Even if nurses actions were onlycontributing cause to the injury

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    Proximate Cause

    PROOF

    Requires that there be areasonably close connection

    between the nurses conductand the resultant injury

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    Foreseeability

    Nurse has a responsibility to foresee

    harm before it occurs and eliminaterisks

    Admission Screens

    Fall Risk

    Suicide Risk

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    Illusion of Negligence

    Ev idence o f the tru th as

    to what real ly happened

    is unavailab le

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    Damages

    Compensated when:

    Suffered loss or injury through the act,omission, or negligence of another

    Medical costs

    Loss of earnings

    Impairment of future earnings

    Past / future pain & suffering

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    Objectives

    1. Explain the importance of documentation as a

    health care provider.

    2. Identify the legal aspects of nursing

    documentation.

    3. Identify the basic information that is required whendocumenting.

    4. Describe specific issues that require

    documentation.

    5. Discuss documentation concerns regarding faxingof records.

    6. Discuss computerized documentation concerns.

    7. Discuss documentation Dos and Donts.

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    Objectives8. Identify how the nursing process impacts nursing

    documentation.9. State characteristics of reasonable documentation.

    10. Explain what constitutes Nursing Malpractice

    related to the role of documentation.

    11. Identify common charting errors.12. Identify the consequences of poor documentation

    13. Discuss the future of documentation standards.

    14. Evaluate the medical record documentation issues

    in selected legal cases.

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    Questions

    What do you want to know?

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    Who Cares?

    Regulations

    Client / Patient

    Insurance

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    "if it's not documented it was

    not done"

    To avoid litigation, health careproviders must comply with

    established standards of care.

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    Standards of Care

    Legislation / Statutes

    Practice Guidelines

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    Prudent Nurse

    Knowledge Skill

    Care Diligence

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    Why Is the Chain of Command

    Important?

    Courts have held that nurses have a duty

    to question a physicians order if it is notconsistent with standard medical

    practice.

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    Initiation of the Chain

    Nurse

    becomes concerned

    Physician

    unresponsive or insufficiently responsive

    might not return a page

    tells the nurse not to call again about thesame problem, or informs the

    nurse he or she will come in later

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    Examples

    Clinical Situations The dose of a

    medication isexcessive or

    inadequate. IV fluid orders are

    incomplete orinconsistent.

    The nurse is

    concerned about fetalheart rate monitoringin a patient in labor.

    The postoperativelaparoscopiccholecystectomy

    patient begins havingsymptoms of an acuteabdominal process.

    The patient has widelydivergent intake

    versus urinary output. The patient is allergicto the medication thephysician orders.

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    Make Documentation Easier

    The Dos

    The Donts

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    The Dos

    Correct Chart

    Reflect the Nursing Process

    Write Legibly

    Permanent Black Ink

    Complete / Concise / Accurate

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    Clear / Concise / Accurate

    Wrong Way: Communication withpatient's family begun today to specify

    the manner in which his condition isprogressing and suggest a probableconsequence of that progression.

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    Clear / Concise / Accurate

    Right Way:I contacted Mr. Boons wife at

    1415 hours. I explained that his cardiacstatus was worsening and that he wasbeing prepared for a cardiac

    catheterization procedure scheduled for1600 hours.

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    Dos

    Medications

    Route

    Clients response

    Precautions / Preventive Measures

    Side rails

    Restraints

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    Dos

    Nursing Procedures

    Name of procedure When it was performed

    Who performed it

    How it was performed

    How well the client tolerated it

    Adverse reactions

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    Dos

    Phone calls

    Health Care Team visits

    Dont wait to Chart

    Client refusals

    Clients subjective data

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    Dos

    Medication omission

    Late Entry

    Not Applicable

    Charting Frequency

    Facility P&P / Standards

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    Dos

    Approved abbreviations & symbols

    Discharge instructions

    Commonly misspelled words

    Look-a-Like / Sound-a-Like

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    Dos

    Continuation

    Triplicate / Carbonated Copies

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    The Don'ts

    Complaints

    Opinions

    Altering the Record

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    Red Flags

    Adding Information

    Dating the entry Dates / Times conflict

    Inaccurate Information.

    Destroying records

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    Dont

    Unapproved Abbreviations

    Shorthand

    Vague

    Excuses

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    Dont

    Chart for someone else

    Chart Opinions

    Use Negative Language

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    Dont

    Use vague terms

    Chart ahead

    Misspelled words

    Incorrect Grammar

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    Dont

    Chart staffing problems

    Chart staff conflicts

    Chart casual conversations

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    Fraud

    Charting care that you haven'tperformed is considered fraud

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    When you make a Mistake

    White out / Eraser

    The word Error

    Correct the Entry

    Oops

    Sad Faces

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    Dont

    Leave empty lines / spaces

    Write in the margins

    Make reference to incident reports

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    Dont

    Use words that suggest that there is aclients safety risk

    Violate client confidentially

    HIPPA

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    Common Charting Mistakes

    Failing to recordpertinent health ordrug information

    Failing to recordnursing actions

    Failing to record that

    medications havebeen given

    Recording on thewrong chart

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    Common Charting Mistakes

    Failing to document adiscontinuedmedication

    Failing to record drug

    reactions or changesin the patientscondition

    Transcribing ordersimproperly ortranscribing improperorders

    Writing illegible orincomplete records

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    Failing to record pertinent health

    or drug information

    The nurse neglected to recordher patients penicillinallergy in the admissionnotes.

    Because the intern didnt knowthe patient was penicillin-allergic, he gave the patienta penicillin injection.

    The patient, who wasincoherent and couldnt tellthe intern about the allergy,

    went into anaphylacticshock and sufferedirreversible brain damage.

    At the trial, the court found thenurse guilty of negligence.

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    Failing to record nursing actions

    The evening nurse notices heavy drainage from thewound.

    She checks the nurses notes and finds no evidence thatthe dressing was changed.

    She considers the amount of drainage normal for a periodof several hours.

    She changes the dressing but, like the day nurse, forgetsto chart her action.

    The night nurse does the same.

    Is the condition getting more serious? Is the patients lifein jeopardy? No one knows because no one realizesthat the patients wound is seeping more than it should.

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    Failing to record that medications

    have been given

    A day nurse gave a patient heparin by intravenous

    push just before she went off duty.

    An hour later, the evening nurse saw the order forheparin--but no indication that it had been given.

    So she gave the patient the same dose.

    The patient began to hemorrhage and went intohypovolemic shock.

    He recovered--then successfully sued the hospital.

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    Recording on the wrong chart

    Mrs. B. Moyer and Mrs. C. Moyer were on thesame unit.

    Mrs. B. Moyer was being treated for severe

    hypertension;Mrs. C. Moyer, for acute thrombophlebitis.

    Mrs. C. Moyers doctor ordered 4,000 units ofheparin for her.

    The nurse mistakenly transcribed the heparinorder onto Mrs. B. Moyers chart andadministered the heparin.

    Mrs. B. Moyer started bleeding.

    Failing to document a

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    Failing to document a

    discontinued medication

    A doctor suspected that his patient, who was takinghigh doses of aspirin for arthritis, had developedan ulcer.

    So he discontinued the medication.

    But the patients nurse forgot to record the order onthe medication sheet, and she and the othernurses continued giving aspirin.

    The ulcer bled, and the patient eventually

    underwent a partial gastrectomy because hercondition deteriorated.

    She sued the hospital for the nurses negligenceand won.

    Failing to record drug reactions

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    Failing to record drug reactions

    or changes in the patients

    condition

    A patient complained of nausea, dizziness,abdominal pain, and itchy skin shortly afterreceiving his first 100-mg dose ofnitrofurantoin macrocrystals (Macrodantin).

    His nurse wasnt concerned, though.

    By evening, after two more doses of the

    medication, he was vomiting and had a highfever, urticaria, and early symptoms of shock.

    He sued his nurse for negligence.

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    Transcribing orders improperly or

    transcribing improper orders

    A doctor ordered 5 ml of atropine for a patient

    on the coronary care unit.He meant to order 0.5 ml, but he didnt includethe zero or write the decimal point clearly.

    The nurse transcribed the order as 5 ml,

    although she didnt think it seemed right.She decided the doctor knew best and didnt

    check the dose before recording it.

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    Writing illegible or incomplete

    records

    To play it safe:

    Print

    Sign your full name and title Dont leave blank spaces, lines, or boxes on charts

    Dont use unapproved abbreviations

    Record every nursing action as soon as possible Write enough to convince the reader

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    METHODS (STYLES) OF CHARTING

    NARRATIVE

    SOAP

    SOAPIER

    FOCUSDATA

    ACTION

    RESPONSE

    PIE

    EXCEPTION CHARTING

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    NARRATIVE

    CHRONOLOGICAL

    BASELINE CHARTED QSHIFT

    LENGTHY, TIME-CONSUMING

    SEPARATE PAGES FOR EACH

    SOURCE-ORIENTED

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    SOAP

    USED FOR PROBLEM-ORIENTED CHARTS

    S SUBJECTIVE. WHAT PT TELLS YOU. 0 OBJECTIVE. WHAT YOU OBSERVE, SEE.

    A ASSESSMENT. WHAT YOU THINK IS GOING ONBASED ON YOUR DATA.

    P PLAN. WHAT YOU ARE GOING TO DO.

    CAN ADD TO BETTER REFLECT NURSING PROCESS I INTERVENTION (SPECIFIC INTERVENTIONS

    IMPLEMENTED)

    E EVALUATION. PT RESPONSE TO INTERVENTIONS.

    R REVISION. CHANGES IN TREATMENT.

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    EXAMPLE OF SOAP CHARTING

    #1 ALTERATION IN COMFORT. ABDOMINAL

    PAIN.

    S COMPLAINS OF PAIN IN RUQ

    O IS PALE AND HOLDING RIGHT SIDE

    A RECURRING ABDOMINAL PAINP PUT ON NPO AND NOTIFY PHYSICIAN

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    FOCUS CHARTING

    USES NARRATIVE DOCUMENTATION

    (DAR) DATA SUBJECTIVE OR OBJECTIVE THAT

    SUPPORTS THE FOCUS (CONCERN)

    ACTION NURSING INTERVENTION

    RESPONSE PT RESPONSE TO INTERVENTION

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    EXAMPLE OF FOCUS CHARTING

    D COMPLAINING OF PAIN AT INCISION SITE

    ON LEVEL OF #7

    A REPOSITIONED FOR COMFORT. DEMEROL

    50MG IM GIVEN.

    R (CHARTED AT A LATER DATE.) STATES A

    DECREASE IN PAIN, FEELS MUCH BETTER.

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    PIE CHARTING

    Similar to SOAP charting

    Both are problem-oriented PIE comes from the Nursing Process,

    SOAP comes from a Medical Model.

    P-Problem

    I-Intervention

    E-Evaluation

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    SAMPLE OF PIE CHARTING

    P#1 Risk for Infection r/t IV Therapy site.

    IP#1 Checked IV Site periodocally.

    EP#1 No sign of redness and swelling on IVsite

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    CHARTING BY EXCEPTION

    USES FLOWSHEETS

    EMPHASIS ON ABNORMAL (WHAT IS ABNORMALFOR THIS PATIENT.

    ALTHOUGH IT MAY BE ABNORMAL FOR THENORMAL PERSON, IF IT IS ABNORMAL FORYOUR PATIENT ON A CONSISTENT BASIS, IT ISNO LONGER CONSIDERED AN EXCEPTION.

    ADVANTAGE

    COMPUTERIZED CHARTING

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    COMPUTERIZED CHARTING PASSWORD. NEVER SHARE. CHANGE

    FREQUENTLY. LEGIBLE

    CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.

    DATE AND TIME AUTOMATICALLY RECORDED.

    ABBREVIATIONS AND TERMS ARE SELECTED BYA MENU PROVIDED BY THE FACILITY.

    TERMINALS ARE USUALLY EASILY ACCESSIBLE,IN PT ROOMS, CONVENIENT HALLWAY

    LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY

    UNAUTHORIZED PERSONS.

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    KARDEX

    QUICK REFERENCE

    CHANGED AS NEEDED

    NOT PART OF PERMANENTRECORD

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    ABBREVIATIONS

    YOU MUST USE YOUR FACILITYS

    APPROVED ABBREVIATIONS.

    BE AWARE THAT A LOT OFCOMMONLY USED ABBREVIATIONS:EG. TID, BID, QOD, HS ARE NOLONGER ALLOWED AND SHOULDBE CURRENTLY BEING PHASEDOUT OF YOUR FACILITY.

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    CHANGE OF SHIFT REPORT

    PERSON TO

    PERSON BE PREPARED

    AVOIDGOSSIP/SOCIALIZ

    ATION

    TAPE RECORDER

    INCIDENT REPORTS

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    INCIDENT REPORTS OBJECTIVE

    DO NOT BLAME OR ADMITLIABILITY

    WHAT DID YOU DO?

    DO NOT INCLUDENAMES/ADDRESSES OFWITNESSES

    DOCUMENT TIME/NAME OFDOCTOR

    DO NOT FILE IN CHART

    DO NOT WRITE INCIDENT

    REPORT MADE

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    CORRECTING ERRORS

    IF YOU SPILL SOMETHING ON THE CHART, DONOT DISCARD NOTES. RECOPY, PUT ORIGINALAND COPIED SHEETS IN CHART. WRITECOPIED ON COPY.

    DO NOT SCRIBBLE OUT CHARTING.

    AVOID USING ERROR OR WRONG PATIENTWHEN MAKING CORRECTION.

    FOLLOW YOUR FACILITIES POLICY.

    DO NOT ALTER CHARTING, IT IS A LEGAL

    DOCUMENT.

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    Lessons Learned

    Documentation validates Nursing Care

    A high-risk patient requires complete

    assessment and frequent monitoring.

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    Defensive Documentation

    Chronological

    Comprehensive

    Complete

    Concise

    Descriptive

    Factual

    Legally aware

    Legible

    Relevance

    Standardabbreviations,

    symbols, and termsThorough

    Timely

    Documentation The right way!

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    Future

    National Standards

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