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Nursing Documentation Back to Course Index

NURSING DOCUMENTATION

 FAVORITE

 
INTRODUCTION

People have been jotting things down for a very long time.  As a matter of fact, research has traced the origin of the written word to Ancient Greece, the Renaissance, and the mid ninth Century.  However, the discipline of technical communication is seen as growing out of the need for accurate and technology-based documentation required by military, industry, health care and other disciplines. Technical communication is the process whereby usable information is communicated through written or spoken information about a specific domain for an intended audience.  The information is deemed usable when the intended audience is able to act upon or make a decision based on its content.  Consequently, the process of developing information products begins by ensuring that the nature of the audience and their need for information is clearly identified.  Technical communication is considered a professional task for which organizations either hire specialized employees or outsource their needs to communication firms. However, in the nursing profession it is incorporated into the daily tasks of professional nurses.

Nursing has a distinguished history of concern for the welfare of the sick, the injured, and others that are in need of care as well as social justice.  One of the essential tasks that must be performed to ensure an equitable outcome is a professional and consistent approach to documentation of patient care and medical history.  When we look at a continuum of care that spans several days, weeks, or months we realize how critical it is for the next shift to know precisely what and when medications were administered and medical procedures performed.  The documentation should always include date, time, event and outcome data as well as any minor details that are relevant to patient care. 

 

NURSING RESPONSIBILITY     2

The nurses primary responsibility is to provide professional patient care and to promote welfare over all other interests.  Nurses are educated and trained to encourage interactions in ways that foster the interest and welfare of patients and promote development of a healthy nurse patient relationship.  Nurses actively attempt to understand the special needs of each patient as well as the diverse conditions and backgrounds of the patients they serve (this includes belief system, morals, languages and ethics).  Nurses also explore their own background and beliefs and how these may affect their values about the nursing processes and their own commitment to excellence and professionalism.

Generating and Maintaining accurate, legible and professional medical records are one of the most important functions of the nursing profession.  Because the  attending nurse often has more direct interaction with the patient than any other caregiver, they are required to maintain patient records that are necessary for rendering professional services to their patients and as required by laws, regulations and/or agency or institution procedures.  Nurses are required to include sufficient and timely documentation in their patients records to facilitate the delivery and continuity of needed services.  Nurses are required to take reasonable steps to ensure that the information contained in their records accurately reflects patient progress and services provided.  If errors are made in patient records, nurses take steps to properly note the correction of such errors according to agency or institutional policies.


PURPOSE

The purpose of this course is to provide nurses with information what will help them conform to and/or exceed the laws and standards governing nursing documentation.  It will also help nurses to comply with the requirements associated with the legal requirements to document a patients medical condition in a formal and proper manner.  Upon satisfactory completion of this course the nurse should be able to:

  •        Meet the professional and legal requirements for generation and maintenance of patient records.
  •        Enhanced knowledge and awareness of negligence as related to patient records.
  •        Enhanced understanding of nursing negligence and be able to reduce or avoid documentation errors that could lead to legal problems.
 
 legalCharting Legal Considerations

The intent of this section is to provide nurses with information about the laws and standards governing nursing documentation.  This section also addresses the legal basics for appropriate documentation as well as the consequences resulting from failure to follow proper procedures.  This section will enable the nurse to:

  •        Understand negligence as related to patient records.
  •        Describe significant characteristics of legally credible charting.
  •        Describe typical charting practices that can lead to legal problems.

    In the past, nurses were less likely to be involved in negligence law suits (than  physicians); however, as the nursing responsibilities have increased they have become more susceptible to negligence lawsuits.  As one might expect, many of the lawsuits are related to improper or inadequacies associated with content of patient records. As a matter of fact, its likely that you or one of your nursing colleagues will become involved in a professional negligence lawsuit or in you will probably know of another nurse who has been or is being sued for negligence.

The nurse must recognize that the patients chart is a legal document that describes the care provided by you and other caregivers. Consequently, your documentation must provide a complete and accurate accounting of your patients condition and the care you provided. If you are asked to testify in a legal action, you may need to recall details that occurred months or even years ago. Without a complete, accurate and legible medical record, you may be unable to defend yourself against allegations of improper care. Effective documentation can be your best defense if you’re named in a lawsuit and may even help in getting the lawsuit dismissed.

Most lawsuits involving nurses are civil cases that attempt to prove that a nurses negligent care resulted in injury to a patient.  As noted previously, negligence occurs when there is a failure to provide a patient with the standard of care that a reasonably prudent nurse would exercise under the same or similar circumstances. The following conditions must exist in order to prove negligence:

  •        When someone acts in a careless way and causes an injury to another person, under the legal principle of “negligence” the careless person will be legally liable for any resulting harm. This basis for assessing and determining fault is utilized in most disputes involving an accident or injury, during informal settlement talks and up through a trial in a personal injury lawsuit.
  •        In negligence claims the plaintiff (the person injured) tries to show that the defendant (the person supposedly at fault):  a) Owed a legal duty of care to the plaintiff under the circumstances; and b) Failed to fulfill (“breached”) that legal duty through conduct or action (this can include a failure to act); and c) Caused an accident or injury involving the plaintiff; and d) Harmed or injured the plaintiff as a result. 

Expressed in nursing terms, the patients attorney must prove the following elements for a valid negligence case (to prove negligence on the part of the nurse:  a) Nurse had a duty to provide care and to follow an established and acceptable standard of care.  b) Nurse failed to meet the standard of care.  c) Nurses failure to perform to acceptable standard of care caused the patients injuries.  d) Patient suffered damages as a result of the nurses negligent actions.

If you face an allegation of negligence, your documentation can make or break your case. Your contention that you provided appropriate care is significantly weakened if you didn’t take the time to document your actions or if your documentation doesn’t clearly show that you met the standard of care. Without a written, legible record you must rely on your ability as a witness to convince a judge or jury that you gave appropriate care despite your failure to properly document the care.   This is difficult situation as one must overcome the apparent lack of professionalism (inadequate or improper documentation) and attempt to convince the court the work was done satisfactorily is a very difficult sell.  Again, the old axiom of if its not documented, it never happened comes into play.  Let me simply say that all nurses need to avoid being put on the legal hot seat if at all possible.

Arguments such as not enough time, too many patients, higher priority work and similar reasons generally have little or no influence on the court.  Remember the patients attorney will use documentation to try to prove that the standard of care was breached; consequently, gold standard number one for every nurse should be to consistently generate complete and accurate medical records, as they are crucial to prove that you met the standard of care.


Standards

The content and control of medical records must comply with acceptable practices of the nursing industry and also meet the requirements of state law.  Nursing documentation is also influenced by professional organizations such as the Joint Commission and the American Nursing Association (ANA).  The Joint Commission covers a broad set of requirements that govern accreditation as well as Quality and Patient Safety.  The ANA standards require that documentation reflect the treatment regime and that it should be ongoing and accessible to all members of the healthcare team.  ANA standards generally reflect the industry consensus; consequently, they carry a great deal of weight in the court. It follows that the legal system has helped nurses know what must be included in patient care documentation to be considered accurate and appropriate.

Laws or administrative rules in each state further outline documentation issues, such as handling of records, falsification of records, and confidentiality.  Regardless of your work setting or nursing specialty, you must document care based upon the requirements of your states Nurse Practice Act. It is left to the reader to research the requirements of the state board (contact the National Council of State Boards of Nursing) in your particular state and to adhere to those requirements.

It is also mandatory that nurses follow documentation policies that have been established by their hospital or other employer.  As noted previously, most healthcare providers require policies and procedures to reflect the requirements of state law, professional nursing standards, and Joint Commission requirements. For example, your hospitals policies should provide the methodology as to how documentation should be done, who is responsible for charting in each part of a patients record, and what charting techniques and procedures are acceptable. However, if your hospitals standards are less strict than those of your Nurse Practice Act, you must adhere to the higher standard.

 
Effective Documentation  3

One thought that should never be very far from a nurses mind is the old axiom: If it wasnt documented, it wasnt done.  Another thought that is very important is that effective documentation should leave no question in a future readers mind that the patients condition was continuously assessed and carefully monitored and appropriate entries were made in the patients chart.  Guidelines for effective communications/charting include items such as timely, accurate, truthful, and appropriate. Timely documentation specifically means documenting care when the care is administered (do not chart in anticipation of performing a task) or as soon as possible thereafter.  Regular entries demonstrate that you are checking your patients condition frequently.  Avoid getting into the habit of waiting until the end of your shift to document as this can result in loss of important details or loss of important information because it slipped your mind or the entry was abbreviated because you were pressed for time.

Accuracy of records relates to the facts about patient care; consequently, chart only events you personally observe (see, hear, smell, or feel).   All entries must be legible, and accurately reflect the patients condition. Avoid generalities and/or vague statements.  For example, charting 20 cm of red blood on bed near left knee is more specific and informative than blood on bed linens.  Avoid meaningless expressions such as patient had a good night or appears or seems.

Also, all documentation must have the following attributes:

  •        Truthful and/or factual (document only what you have observed and/or administered).
  •        Appropriate (include only information that you would be comfortable with if it was exposed during a legal matter)
  •        Uniformity and consistently (adhere to your hospitals documentation policies about issues such as late entries, legible charting, record confidentiality, standard abbreviations, cosigning and patient refusal of treatment.
  •        Safety (document any safety precautions you implement, such as using restraints).
  •        Keep record professional (avoid personal comments related to peers and/or references to inadequate care).  These issues should be taken to your supervisor, as they dont fit in the patients record.
 
Litigation

Patient medical records may not be altered once litigation has started.  No information should be added or deleted (by anyone, nurse, colleague, staff, supervisor or others) as experts can determine when various entries were made and which ones were altered.   If you suspect that another healthcare professional has made illegal changes to a patients chart, notify your nursing supervisor immediately. Tampering/altering with a patients chart is illegal and can cause the patient record to be inadmissible in court.  Also, a nurse can be charged with falsification of records and/or fraudulent care if care was document that was not provided.  The plan of care is the primary component that can be documented before it is done. 

Your legal risk increases if you fail to clearly describe situations that are out of the norm and/or that you consistently use high-risk abbreviations.  Extra effort should be taken to describe in detail any and all situations that are out of the ordinary or if an unexpected outcome is observed.  As for abbreviations, the Joint Commission identified improves the effectiveness of communications among care givers as one of its initiatives in January 2004.  This along with other initiatives led to the following Do Not Use list of abbreviations:

 

Do Not Use

Potential Problem

Use Instead

U (unit)

Mistaken for O (zero), the Number 4 (four) or cc

Write unit

IU (International Unit)

Mistaken as IV (Intravenous) or the number 10 (ten)

Write International Unit

Q.D., QD, q.d., (daily)
Q.O.D., QOD, q.o.d., qod
   (Every other day)

Mistaken for each other,
Period after the Q mistaken for I, and the O mistaken for I

Write daily
Write every other day

Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)

Decimal point is missed

Write X mg
Write 0.X mg

MS, MSO4 and MgSO4

Can mean morphine sulfate or Magnesium Sulfate
Confused for one another

Write morphine sulfate
Write magnesium sulfate

Additional Abbreviations, Acronyms and Symbols
(For possible future inclusion in the official Do Not Use list)

> (greater than)
< (less than)

Misinterpreted as the number
7 (seven) or the letter L
Confused for one another

Write greater than
Write less than

Abbreviations for drug names

Misinterpreted due to similar abbreviations for multiple drugs

Write drug name in full

Apothecary units

Unfamiliar to many practitioners
Confused with metric units

Use metric units

@

Mistaken for the number 2 (two)

Write at

cc

Mistaken for U (units) when poorly written

Write ml or milliliters

g

Mistaken for mg (milligrams)
Resulting in one thousand-fold overdose

Write mcg or micrograns

 

It is strongly recommended that the aforementioned Do Not Use list of abbreviations and symbols be avoided in all patient related medical records.

Another practice that can lead to disharmony in the courtroom is to describe a patients behavior as uncooperative, difficult, or manipulative or referring to the patient in a sarcastic manner.  The prosecuting attorney may challenge the nurses professionalism by showing the nurse did not respect or value the patient. The patient behaviors should be described in a factual and impartial manner.


Sentinel Events

The Joint Commission refers to a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury typically includes loss of limb or function.  The phrase, or the risk thereof includes any process variation for which recurrence would carry a significant chance of a serious adverse outcome.  Such events are called sentinel because they signal the need for immediate investigation and response.  Sentinel events generally constitute crises and requires a rapid response from all caregivers; consequently, they are generally very difficult to manage in that a nurse is faced with an emergency situation with a patient and is still required to maintain all other functions such as documentation. It is not surprising that these events are often the basis for legal actions against caregivers using poor communication and documentation as the catalyst to spring the lawsuit.  Needless to say its extremely important to document care as it is provided especially during an emergency situation.

During a sentinel event it is fairly common for nurses to be held liable for failure to observe and report when a patients condition undergoes a rapid change.  If these changes are not reported immediately it is an indication of lack of observation on the part of the nurse.  Accusations of failure to adequately observe and monitor can be substantially countered by accurate and detailed documentation.

Another of the more common legal issues arises due a nurses failure to properly notify the physician about changes in the patients condition. These situations are often serious, and may result in death or disability of the patient. A nurse always has the responsibility to intervene on behalf of their patient and to take whatever action is appropriate. The intervention often involves contacting the physician followed by carrying out whatever therapy the doctor prescribes.  In many cases, your legal obligation goes beyond carrying out prescribed treatment. For example, if in your professional judgment you consider the physician orders to place a patient in jeopardy, you must intervene on behalf of the patient and clarify the treatment plan with the physician. Some recent malpractice cases have hinged on whether the nurse was persistent enough in an attempt to notify the physician or to convince him or her of the seriousness of the situation. Nurses who fail to continue to question inappropriate orders by contacting a nursing supervisor or going up the chain of command can be held liable for failure to intervene because the intervention was below what is expected of them as patient advocates.

If a physician must be notified, you must be able to communicate essential information in a clear and concise manner. Communication is generally by phone and this type of communication is generally less effective than face-to-face as the nonverbal clues are eliminated.  Consequently, when you are communicating via the phone the information must be presented in a manner that will enable the physician to develop a visual image of the situation.  On weekends, you may talk with someone other than the primary care physician; consequently, it is essential that you provide background information before describing the problem.

You must document each time you phone a physician, even if no one answers. If you have a conversation then document the details including the therapy prescribed.  Also, document the physician spoken to by name rather than referring to him or her as the MD or the doctor.  If, in your professional opinion, you don’t believe the physician is responding appropriately, you’ll need as much supporting documentation as you can get as a legal safeguard. Note specifically the details you reported, time of contact, time new orders or no orders were received, and additional actions you take.  If you don’t note the time you called, allegations could be made later that you failed to obtain timely medical treatment for the patient. Always note in the chart the specific change in the patients condition or diagnostic test result that prompted your call to the physician. If you’re reporting a crucial lab result, such as an elevated blood pressure, but don’t receive an order for intervention, be sure to verify with the doctor that he or she doesn’t want to give an order. Your documentation should note: Dr. Brown notified of high blood pressure (155/95). No orders received.

Minimizing legal risks is important in today’s healthcare climate especially when one recognizes that we have a proactive legal system. Comprehensive documentation that reflects the treatment modalities as well as the nursing process is essential for survival in the healthcare industry today.  Remember that patients records and what they contain is the single most important tool available to a nurse facing a charge of negligence.  As stated previously, legally credible and legible documentation provides a written record of the care your patient received and evidence that you met an acceptable standard of care.

The following actions are recommended to provide your patient with optimum care and while protecting yourself and your employer from legal action:

  •        Adhere to your states nurse practice act.
  •        Dedicate yourself to following professional standards for documentation at all times. Ensure that all documentation is accurate, timely, and legible and meets or exceed the standard of care that has been established by your colleagues and peers.
  •        Adhere to your hospitals policies and procedures and seek assistance from your supervisor as required. 

Charting Mistakes to Avoid

The following charting mistakes are fairly common and have led to numerous lawsuits:

       Improper drug dosage recorded:  May lead to over or under dose in subsequent applications.

 

       Failure to record disease and/or allergies: For example, if a patient is allergic to a specific medication then the caregiver needs to be informed about his or her condition.  If information such as this is not compiled and transmitted to appropriate caregivers then you may be subject to a negligence lawsuit.  Some hospitals alert other staff members to drug allergies by putting a label on the outside of the patients chart.

 

       Nursing actions not properly recorded:  All interventions    must be properly recorded on the patients chart.  The usual excuse for not charting is insufficient time.  At high stress times this may be a valid reason; however, the court does generally not accept it. 

 

       Failure to record medications when given:  Improper recording can result in either an under dose or overdose.

 

       Wrong chart used to record data:  avoid confusion by always verifying patient/chart comparability.

 

       Failure to document a discontinued medication:  Crosscheck the medication against the physicians order.

 

       Failure to document a patients reaction to a medication:  Monitor the patient often to detect any negative reaction to any mediation.  Alert the doctor immediately if an unexpected outcome occurs.

 

       Transcriptions errors:  Verify prior to use any time you are unsure about either the medication or dosage. 

 

       Writing illegible records:  Print if your hand writing is poor; Avoid abbreviations that aren’t approved by hospital; document sufficiently to show the patient was cared for and that you met the standard of care.

 

Recommendations  computer
Every individual and/or organization needs plan to monitor the quality of his or her output.  The following is recommended for nurses with respect to their documentation:

 

       Self-audits:  Randomly choose patient records that you have generated.  Review the records to see if they are complete, contain the proper information, and are legible.  If you struggle to understand the record it would be difficult to defend in court.

       Peer reviews:  Essentially the same as a self-audit except peers are looking at the records.  If this group has difficulty understandings the record then it could be troublesome in court.

 

If problems are identified then corrective actions should be taken immediately.  The team goal should be to establish an acceptable standard of care in your hospital.

 
 
References

American Nurses Association website

Joint Commission website

State Nurses Practice Act website

Various other websites