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Southern California Patient Safety

Collaborative Tract IIICollaborative - Tract III

OB Documentation:Knowing the Write

I f tiInformationMary Ellen Filbey, RN, BSN, JD, CPHRMClinical Risk and Patient Safety Specialist and MOREOB Program Lead Consultant

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Objectives/Agenda

• Discuss purposes of medical record documentation

• Recognize documentation errors

• Recognize challenges of using the variousRecognize challenges of using the various medical record formats

• Identify OB documentation best practices for some high-risk presentations

• Discuss your examples and best practices and have some fun!

What Do We Know?

• Frequency and severity of perinatal claims

• Median Obstetrical Malpractice awards

• The Joint Commission’s Sentinel Event Alerts

• Obstetrical claims are studied and studied• Obstetrical claims are studied and studied

What Contributes to OB Claims the Most?

Source: Crico Strategies, 2010: Annual Benchmarking Report – Malpractice Risks in Obstetrics, Crico Strategies, Cambridge, MA 2011, p. 7, http://www.rmfstrategies.com/Products-and-Services/Comparative-Data/~/media/Files/Strategies/Reports/2010_annual_benchmark.pdf, 03/30/2012.

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Patterns: Losing Malpractice CasesFour patterns linked to almost two-thirds of malpractice losses:

• Three are associated with avoidable adverse outcomes:– Use of oxytocin, misoprostol and magnesium sulfate

– Deterioration in fetal status requiring expeditious cesarean delivery

– Management of VBAC

• Incomplete Documentation:– Shoulder dystocia

Source: S. L. Clark, M. A . Belfort, G. A. Dildy and J. A . Meyers, “Reducing Obstetric Litigation Through Alterations in Practice Patterns,” Obstetrics & Gynecology, Vol.112, No. 6, December 2008, pp. 1278-83.

Frequent Allegations: Documentation

• Inadequate prenatal history• Incomplete and inadequate physical

examination• Failure to observe and take appropriate action:

– Poor risk assessment/reassessment– Delay in or lack of response to non-reassuring fetal

status– Delay in performing cesarean

Source: Kathleen Rice Simpson and G. Eric Knox, “Common Areas of Litigation Related to Care During Labor and Birth: Recommendations to Promote Patient Safety and Decrease Risk Exposure,” Journal of Perinatal and Neonatal Nursing, Vol. 17, No. 2, April/June 2003, pp. 110-125.

Frequent Allegations: Documentation

• Failure to communicate changes in patient’s condition

• Failure to use/interpret fetal monitoring appropriately

Source: Kathleen Rice Simpson and G. Eric Knox, “Common Areas of Litigation Related to Care During Labor and Birth: Recommendations to Promote Patient Safety and Decrease Risk Exposure,” Journal of Perinatal and Neonatal Nursing, Vol. 17, No. 2, April/June 2003, pp. 110-125.

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Polling Question: EFM Certification

• Nurses?

• Providers?– Nationally or other programs

• Consistently using Category Language in documentation?

• Share how you bridged the gap

Frequent Allegations: Documentation

• Inappropriate use of Pitocin

• Communication– Finger-pointing– Assigning blameg g– Disparaging comments

Documentation is a key communication issue in

i t l iperinatal services.

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Documentation –at the Center of it All!

Patient Care

Performance Improvement

Public Reporting

Documentation

Reimbursement

RegulatoryAccreditation

Malpractice Defense

Importance of Documentation

Essential Elements - AIR-C2

Interventions

Assessment Response

Changes

Communication

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Attorneys Look at the Basics First

• Date, time and sign each entry

• Draw a line through the empty space at the end of an entry/bottom of page

• Note the patient’s name on each pageNote the patient s name on each page

• Document at the time of treatment and procedures

Are You Covering the Basics?

• Make sequential entries

• Appropriately add late entries

• Chart personal observations of subjective and objective dataobjective data

• Make and sign your own entries

• Always chart in ink and legibly

Errors Follow Dangerous Abbreviations

High Error Risk Safe

U or IU Unit or International Unit

Q.D., QD, q.d., qd daily

Q.O.D., QOD, q.o.d, qod Every other day

Trailing zero (X.0 mg) X mg

Lack of leading zero

(.X mg)0.X mg

MSmorphine sulfate

magnesium sulfate

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Scrutinizing Your Documentation!

• What is each side looking for in your documentation?

• Plaintiff?

• Defense?Defense?

Correct Your Errors Consistent with Your Hospital’s Policy

• Hospital policies differ

• Know your hospital’s policy or electronic method to correct an error

• One example:One example:

Are You Being Ambiguous?

• “Squeezing in” some critical information omitted from the record

• Using vague terms such as “fair” or “apparently” or “better” - be descriptivep

• Documenting premature conclusions - “probably heartburn” or “most likely fetus sleeping”

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Subjective Comments are Easily Misinterpreted

What is the big deal? All I did was document that the doctor looked tired

that night.

Are You Implying Bias?

• Referencing anything related to billing/insurance

• Describing a patient in an inflammatory or prejudicial manner

Documenting Provider Unavailable7/8/11 2100 Dr. Stetrics paged regarding patient’s condition. Mary Ellen Filbey RN

7/8/11 2105 Susy Surgery, RN, from the Operating Room, calls and states Dr.

Stetrics in surgery and to call his partner Dr. Wright.

Mary Ellen Filbey RN

7/8/11 /8/2115 Dr. Wright called at 2108 with no response. Nursing supervisor,

Bessy Body, RN, notified of situation Mary Ellen Filbey RN

2118 Dr. Responsible, Chairperson of OB, called and discussed patient’s condition and request for physician evaluation. Dr. Responsible coming to unit to evaluate patient. Mary Ellen Filbey RN

2121 Dr. Responsible at patient’s bedside to evaluate patient.

Mary Ellen Filbey RN

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High Reliability Perinatal Units

• Clear Purpose: Safety First

• Clear Language: Fetal well-being

• Clear Organization: Teamwork

• One Policy: A physician will come when• One Policy: A physician will come when requested

• Clear operating style

Source: G. Eric Knox, Kathleen Rice Simpson, and Thomas J. Garite, “High Reliability Perinatal Units: An Approach to the Prevention of Patient Injury and Medical Malpractice Claims,” Journal of Healthcare Risk Management, Spring 1999.

Are You Referencing Confidential QA Documents?

Avoid referring to:

• Occurrence/patient safety event reports

• Risk management

• Quality assurance/improvement• Quality assurance/improvement

• Peer review activity

Documenting an Adverse Event

If an adverse event occurred with your patient while you were caring for him/her, how would you document it?

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Adverse Events – Core Elements

The Facts

Care Provided

Patient Response

Physician Notification

Conversations -Patient/Family

Documentation Tools

• Paper

• Electronic

• Hybrid

Paper – Ambiguous Markings

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Electronic Options are Often not Specific Enough

OB examples: – “RN reviewing tracing”

– “Contraction pattern assessed”

Building Your Electronic Documentation

• Checklist information

• Built in templates:– Phase of labor

– Components to consider pfor high risk

• Revisit and update checklists and drop-down options

OB is High Risk

ContinuumEmergency 

V ACShoulder

Vacuum i /

Continuum of Care

Cesarean Section

VBAC sShoulder Dystocia

Extraction/ Forceps

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Prenatal Record Documentation

• Information used for determining dates

• Screening and assessments

• Screening for neural tube defects and genetic testing offered or performed, as indicatedg p

• Patient education and instructions

• The delivery plan with clinical rationale

Fetal Monitoring

http://www.sxc.hu/photo/133305

Continuum of Care

FETAL MONITORING

PrenatalLabor 

Evaluation/ Triage

Transfer AntenatalPost 

Partum

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Good Documentation Counts

Fetal heart tracing has been a Category 1

from 0200 through 0215. I have been with

the patient all this time and continually

0215

03/13/11

the patient all this time and continually

evaluated the fetal status.

Mary Ellen Filbey RN

Labor Evaluation/TriageTransfer

http://www.sxc.hu/photo/133320

Antenatal

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Labor and Delivery Record Documentation

• Initial assessment– Maternal and fetal status, status of labor

• Periodic evaluations of labor– Emphasis on maternal and fetal status and plans or p p

interventions

• Ongoing documentation during later stages of labor and in lengthy labors – Reflect continued clinical evaluation

Labor and Delivery Record Documentation

• Demonstration of thought process

• Discussions with the mother, significant other, and family, as appropriate

• Maneuvers used in the order utilizedManeuvers used, in the order utilized– Vaginal delivery of singleton breech

– Shoulder dystocia

Information FlowReferrals

• PCP should verify that the patient was seen by the specialist

• OB/GYN, MFM, or other specialist should phone the treating physician if the results of p g p ythe referral are adverse

• PCP, OB/GYN, MFM and other specialists need tracking systems to monitor need for follow-up -- all are responsible!

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High-Risk Medication - Pitocin

Photo source: Kym McLeod, http://www.sxc.hu/photo/1100587, 03/30/2012.

Consistent terminology and documentation roles

Emergency Cesarean Section

Photo source: Kerryn du Plessis, http://www.sxc.hu/photo/726035 , 03/30/2012.

VBACs

Photo source: Matt Williams, http://www.sxc.hu/photo/396692, 03/30/2012.

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Shoulder Dystocia –What to Document!

Photo source: Allison Cooper, http://www.sxc.hu/photo/398188, 03/30/2012.

Vacuum Extraction/Forceps –Documentation Considerations

Photo source: Carlos Paes, http://www.sxc.hu/photo/230993, 03/30/2012.

Polling Question

Use of template language or checklist:

• Shoulder Dystoci?

• Operative Deliveries?

• Successes?

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Post Partum

Still High Risk – Be Vigilant and Diligent

Know How Your Documentation Supports the Care Your Team

Provided

Is Your Healthcare Organization a Safe Place to Receive and Give Care?

What are your communication responsibilities to ensure the safety of patients?

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Documentation Strategies to Enhance Communication

• Transmit complete prenatal records to L&D• Coordinate birth plan of care with

interdisciplinary team members, e.g., pediatrics, neonatology, social workers - documentE ff ti i ti f l t• Ensure effective communication of relevant information - document

• Utilize transfer documentation and follow any established written transfer agreements

Documentation Strategies to Enhance Communication

• Implement NICHD terminology

• Require EFM certification

• Ensure that evidence-based perinatal practice protocols/bundles, order sets are built inprotocols/bundles, order sets are built in

• Ensure consensus on definitions/nursing interventions such as for intrauterine resuscitation

Perinatal Documentation Strategies

• Utilize structured prenatal, labor and delivery forms

• Utilize the forms accurately and completely• Supplement the forms with progress notes• Document patient education literature that

was provided• Include a copy of discharge instructions in the

patient’s record

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Strategies to Enhance Documentation for the team

Print off and audit your records

• Including how late entries look

• Know what your electronic records look like for a deposition or in trialfor a deposition or in trial

• Identify opportunities to enhance the electronic record with your IT department

Departing Thoughts

• A good chart defends itself and those who wrote it.

• A chart is a witness that never dies or never lies.

Thank You and Questions

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