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Slide 1: Nursing Documentation Your License may depend on it!
Slide 5: CE ANNOUNCEMENTS Participants must attend entire session to get CE Credit. There are no influential financial relationships, planners, and/or presenters. There is no commercial support that has influenced the planning of this educational activity or content. There is no endorsement of any product by NCNA associated with this program. This program does not relate to products governed by the Food and Drug Administration. If, so appropriate and off-label use will be shared.
Slide 6: Taking a Poll 1. Have you been involved in a patient (client) related lawsuit ? 2. Do you have professional liability insurance? 3. Do you feel like your documentation would support you in a court of law?
Slide 7: A patient you cared for 9 months ago is unhappy with the outcome and has filed a malpractice lawsuit against you. Now what?
Slide 8: The Jury
Slide 14: Legal Case Studies http://www.nso.com/case/com_index.php
Slide 15: What does the “jurors” see and hear?? http://www.youtube.com/watch?v=97O7Od6F8PM Lawyer – types of med. Malpractice http://www.youtube.com/watch?v=S2qv5J2S3ec&NR=1 Lawyer – explains med. Malpractice http://www.youtube.com/watch?v=226MGeCuHAY News Clip – ER Death http://www.youtube.com/watch?v=2xQx24v48ME Lawyer – good opening statement
Slide 16: “Duty of Care” • Based on existence of the nurse-patient relationship • A legal status created when the nurse is legally obligated to provide nursing care to a patient • Law will demand that the nurse perform as a reasonably prudent nurse
Slide 17: Breach of Duty Nurse’s care fell below the acceptable Standard of Care Results: malpractice case – compensatory $$$ loss of nurse’s license loss of job / ability to work
Slide 18: Nursing Negligence / Malpractice • Any action by a nurse that falls below generally accepted standards of nursing care, and causes injury to a patient • Even if nurses actions were only contributing cause to the injury
Slide 19: Proximate Cause “PROOF” Requires that there be a reasonably close connection between the nurse’s conduct and the resultant injury
Slide 20: Foreseeability Nurse has a responsibility to foresee harm before it occurs and eliminate risks • Admission Screens • Fall Risk • Suicide Risk
Slide 21: Illusion of Negligence Evidence of the truth as to what really happened is unavailable
Slide 22: 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
Slide 24: 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 when documenting. 4. Describe specific issues that require documentation. 5. Discuss documentation concerns regarding faxing of records. 6. Discuss computerized documentation concerns. 7. Discuss documentation Do’s and Don’ts.
Slide 25: Objectives 8. Identify RN’s liability for LPN & CNA’s. 9. Identify how the nursing process impacts nursing documentation. 1. State characteristics of reasonable documentation. 2. Explain what constitutes Nursing Malpractice related to the role of documentation. 3. Identify common charting errors. 4. Identify the consequences of poor documentation 5. Discuss the future of documentation standards. 6. Evaluate the medical record documentation issues in selected legal cases.
Slide 26: Questions • What do you want to know?
Slide 27: Who Cares? • • • • State Regulations Federal Regulations Client / Patient Reimbursement
Slide 28: "if it's not documented it was not done" To avoid litigation, health care providers must comply with established standards of care. care
Slide 29: Standards of Care • State & Federal Legislation / Statutes • Practice Guidelines
Slide 30: North Carolina • Know your state’s regulations & statues • The Purpose – to clarify the legal scope of practice & accountability
Slide 31: Learn - CEUs
Slide 32: Practice
Slide 33: http://www.ncbon.com/Practice.asp
Slide 34: Prudent Nurse • Knowledge • Skill • Care • Diligence
Slide 35: Liability: Chain of Command The Nurse’s Duty to Intervene— Initiating the Chain of Command
Slide 36: What Is the Chain of Command? Specific course of action involving administrative and clinical lines of authority Established to ensure effective conflict resolution
Slide 37: Chain of Command? • Clear Understanding • Established Philosophy • Procedure & Policy Nurse’s responsibility to recognize problems with patient care and take appropriate action to prevent patient injury.
Slide 38: Albemarle’s Philosophy
Slide 39: Albemarle’s Chain
Slide 41: Why Is the Chain Important? Courts have held that nurses have a duty to question a physician’s order if it is not consistent with standard medical practice.
Slide 42: 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 the same problem, or informs the nurse he or she will come in later
Slide 43: Examples Clinical Situations • The dose of a medication is excessive or inadequate. • IV fluid orders are incomplete or inconsistent. • The nurse is concerned about fetal heart rate monitoring in a patient in labor. • The postoperative laparoscopic cholecystectomy patient begins having symptoms of an acute abdominal process. • The patient has widely divergent intake versus urinary output. • The patient is allergic to the medication the physician orders.
Slide 44: Documenting This Process “Chain of Command” • Record events and observations in the patient’s medical record in an objective and clear manner. • Document the specific facts, and carefully record the time of each entry as accurately as possible. • Avoid finger pointing and personal attacks on the physician.
Slide 45: Policy & Procedure Well known by all Improves the quality of care Improves patient outcomes
Slide 46: Negligence? • Practice guidelines • Facility policies/procedures http://ahweb/intranet/Policies/Nursing%20Policies/Nursing%20Standards.pdf http://www.youtube.com/watch?v=TaV1gL3xzbE
Slide 47: Expert Witnesses • Used by both prosecuting and defense attorneys to establish standards of care
Slide 48: Responsibility • • • • Stay informed Hospital Policy & Procedures Board of Nursing Standards of Care
Slide 49: Source of Liability • The medical record can change the entire climate surrounding a lawsuit • Medical records, in themselves, may be the very source of a lawsuit
Slide 50: Documentation Standard Policy • Failure to Document • False Documentation – Facility Policies – Law(s)
Slide 51: Case in Point • Case Scenario
Slide 52: Master of Charting • Prevent a malpractice suit
Slide 53: The Basics • • • • • • • Chronology: Date and Time Client History Interventions: Medical, Social and Legal Observations: Objective and Subjective Outcomes Client and Family Response Authorship: Your Signature and Credentials
Slide 54: Legibility • Hand written – Cursive – Print • Computerized – Typed notes – Clicks
Slide 55: Date & Time • Sequence of Events • Lapse in Time • Late Entries • Blocked Time • Military vs Standard Time
Slide 56: Client’s History • Including unhealthy conditions or risky heath habits such as: – scalp lice – smoking – failure to take prescribed medication, etc.
Slide 57: Subject & Objective • • • • See Hear Feel “Think”
Slide 58: Changes in Health Status • Your actions • Clients response • Client outcomes
Slide 59: Client Outcomes • Expected • Deviations
Slide 60: Expectation: Pain Scale
Slide 61: Documentation of Assessment
Slide 62: Actual Response Evaluations • Verbal • Non-verbal
Slide 63: Your Signature • • • • Full name Credentials Job title Initials - SD RN , CC RN ucator ncan Ed D u CU e li a I Sh
Slide 64: A Little More than The Basics • • • • • • Client/Family Education/Instructions Referrals to Community Resources Authorizations and Consents Plans for Follow-up Discharge Plan Telephone Calls: Be Specific
Slide 65: Client Education • Family • Significant Other
Slide 66: Standard Education
Slide 67: Referrals & Consents • • • • Standard Consent Forms Referrals: Client Specific Facility Resources Community Resources
Slide 69: SBAR • • • • S – Situation B – Background A – Assessment R - Recommendation
Slide 70: Phone Calls • • • • • Phone Record Phone Orders Pager Response Documentation Facility Policy
Slide 71: Client Call Office Scenario Date and time of call Caller's name and address Caller's request or chief complaint Advice you gave Protocol you followed (if any) Other caregivers you notified Your name
Slide 72: Client Call Hospital Scenario Date and time of call Physician’s name Client’s chief complaint Information your provided Protocol you followed (SBAR) Order’s received / not received
Slide 73: “Read Back” Date and time of call Physician's name and "T/O" to indicate order Verbal order, written word-for-word Documentation that you've read back the order, to be sure you heard it correctly Documentation that you've transcribed it according to your facility's policy Your name
Slide 74: Faxes & Computerized Records • Facts on Faxing Records • Computer Charting
Slide 75: Safeguards for Faxing 1. Check the number before you dial. 2. Check the number on the fax machine display. 3. Re-check the number before you press the “send” button.
Slide 76: Computerized Documentation • Easier form of communication • Legible • As legal as when you manually chart
Slide 77: Guide to Computer Documentation • Double-check entries • Password security • Do NOT share your code!
Slide 78: Guide to Computer Documentation • • • • • “HIPPA” computer display Log off Printouts P&P for computer entry errors Backup files – Galactica?
Slide 79: Guide to Computer Documentation Patient data, Confidentiality, and Disclosure • state's rules and regulations • facility's policies and procedures • permanent part of the medical record
Slide 80: Guide to Computer Documentation Good computerized documentation not only can help you in court, but it can also keep you out of court in the first place.
Slide 81: Make Documentation Easier • The Do’s • The Don’ts
Slide 82: The Do’s • • • • • Correct Chart Reflect the Nursing Process Write Legibly Permanent Black Ink Complete / Concise / Accurate
Slide 83: Clear / Concise / Accurate Wrong Way: Communication with Way patient's family begun today to specify the manner in which his condition is progressing and suggest a probable consequence of that progression.
Slide 84: Clear / Concise / Accurate Right Way: I contacted Mr. Boon’s wife at 1415 hours. I explained that his cardiac status was worsening and that he was being prepared for a cardiac catheterization procedure scheduled for 1600 hours.
Slide 85: Do’s • Medications – Route – Client’s response • Precautions / Preventive Measures – Side rails – Restraints
Slide 86: Do’s • Nursing Procedures – Name of procedure – When it was performed – Who performed it – How it was performed – How well the client tolerated it – Adverse reactions
Slide 87: Do’s • • • • • Phone calls Health Care Team visits Don’t wait to Chart Client refusals Client’s subjective data
Slide 88: Do’s • • • • Medication omission Late Entry Not Applicable Charting Frequency – Facility P&P / Standards
Slide 89: Do’s • • • • Approved abbreviations & symbols Discharge instructions Commonly misspelled words Look-a-Like / Sound-a-Like
Slide 90: Do’s • Continuation • Triplicate / Carbonated Copies
Slide 91: The Don'ts • Complaints • Opinions • Altering the Record
Slide 92: Red Flags • Adding Information • Dating the entry – Dates / Times conflict • Inaccurate Information. • Destroying records
Slide 93: Don’t • • • • Unapproved Abbreviations Shorthand Vague Excuses
Slide 94: Don’t • Chart for someone else • Chart Opinions • Use Negative Language
Slide 95: Don’t • • • • Use vague terms Chart ahead Misspelled words Incorrect Grammar
Slide 96: Don’t • Chart staffing problems • Chart staff conflicts • Chart casual conversations
Slide 97: Fraud Charting care that you haven't performed is considered fraud
Slide 98: When you make a Mistake • • • • • White out / Eraser The word “Error” Correct the Entry Oops Sad Faces
Slide 99: Don’t • Leave empty lines / spaces • Write in the margins • Make reference to incident reports
Slide 100: Don’t • Use words that suggest that there is a client’s safety risk • Violate client confidentially – HIPPA
Slide 101: RN * LPN * CNA Differences • RN – Nursing process • CNAs & LPNs – Flow charts & check lists
Slide 102: WHEN THE LICENSED NURSE DELEGATES PATIENT CARE ACTIVITIES TO UAPs
Slide 103: WHEN THE PHYSICIAN DELEGATES PATIENT CARE ACTIVITIES TO UAPs
Slide 104: RN • Care Plan • Standardized Care Plan • Clinical Pathway
Slide 105: Standardized Nursing Care Plan • Formatted - the nurse checks off care provided. • The Nurse Individualizes the care plan specific to each patient
Slide 106: Clinical Care Path – Nursing actions for a specific medical diagnosis. – Specifies daily care required • including but not limited to: – diet, medications, activity, treatments – The goal: progress to discharge
Slide 107: Kardex • Card system - readily accessible to all members of the health care team • Quick reference
Slide 108: Computerized Kardex
Slide 109: Nurses Notes • • • • • • Narrative SOAP SOAPIE SOAPIER APIE PIE • Graphic Charting • Focused Charting • Charting by Exception
Slide 110: Nurses Notes Narrative • Narrative – Chronological – Legibility – Format
Slide 111: Universal Guideline for Charting “Nursing Process” Four phases of nursing care: Assessment Planning Implementation Evaluation
Slide 112: Documentation Audits • Random Audits • Quality / Performance Initiatives
Slide 113: How to prove Malpractice • Improper or negligent treatment of a patient, as by a physician, resulting in injury, damage, or loss. • Improper or unethical conduct by the holder of a professional or official position. • The act or an instance of improper practice.
Slide 114: Common Charting Mistakes • Failing to record pertinent health or drug information • Failing to record nursing actions • Failing to record that medications have been given • Recording on the wrong chart
Slide 115: Common Charting Mistakes • Failing to document a discontinued medication • Failing to record drug reactions or changes in the patient’s condition • Transcribing orders improperly or transcribing improper orders • Writing illegible or incomplete records
Slide 116: Failing to record pertinent health or drug information The nurse neglected to record her patient’s penicillin allergy in the admission notes. Because the intern didn’t know the patient was penicillinallergic, he gave the patient a penicillin injection. The patient, who was incoherent and couldn’t tell the intern about the allergy, went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the nurse guilty of negligence.
Slide 117: Failing to record nursing actions The evening nurse notices heavy drainage from the wound. She checks the nurses’ notes and finds no evidence that the dressing was changed. She considers the amount of drainage normal for a period of several hours. She changes the dressing but, like the day nurse, forgets to chart her action. The night nurse does the same. Is the condition getting more serious? Is the patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should.
Slide 118: 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 for heparin--but no indication that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered--then successfully sued the hospital.
Slide 119: Recording on the wrong chart Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe hypertension; Mrs. C. Moyer, for acute thrombophlebitis. Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her. The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin. Mrs. B. Moyer started bleeding.
Slide 120: Failing to document a discontinued medication A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer. So he discontinued the medication. But the patient’s nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin. The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for the nurses’ negligence and won.
Slide 121: Failing to record drug reactions or changes in the patient’s condition A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). His nurse wasn’t concerned, though. By evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and early symptoms of shock. He sued his nurse for negligence.
Slide 122: 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 didn’t include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml, although she didn’t think it seemed right. She decided the doctor knew best and didn’t check the dose before recording it.
Slide 123: Writing illegible or incomplete records To play it safe: • Print • Sign your full name and title • Don’t leave blank spaces, lines, or boxes on charts • Don’t use unapproved abbreviations • Record every nursing action as soon as possible • Write enough to convince the reader
Slide 124: Documentation – The wrong way! • Legal situations
Slide 125: Ketchum vs. Overlake Hospital Medical Center 1991 Ms. Ketchum sued Overlake Hospital, contending that her severe mental retardation was caused by what she felt was negligent nursing care.
Slide 126: Expert Nurse Witness Prosecution • Assessment • Documentation • Report Changes
Slide 127: Expert Nurse Witness Defense • Assessment • Documentation • Report Changes
Slide 128: Pivotal Issue • Documentation
Slide 129: Jarvis vs. St. Charles Medical Center 1986 Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which was subsequently surgically reduced
Slide 130: Pivotal Issues • Reporting Problems • Following Orders
Slide 131: Inconsistent Nurses Notes • Standard of Nursing Care This case truly epitomizes the old saying that if the care was not documented, then it was not done It was as though a nurse never checked the client during that time period.
Slide 132: Ard vs. East Jefferson General Hospital Five days after quintuple coronary artery bypass graft surgery, a patient who was having respiratory problems was transferred out of the intensive care unit (ICU).
Slide 133: Nurse Availability Call Bell • Standard Practice
Slide 134: Wrongful Death • The basis for a lawsuit, which is filed due to a death caused by the negligence of another person
Slide 135: Nurse Expert • Breach in Standard of Care • Failure to address high risk problem • Failure to complete full assessment
Slide 136: Medical Expert • Change the Outcome
Slide 137: Lessons Learned • Documentation validates Nursing Care A high-risk patient requires complete assessment and frequent monitoring.
Slide 138: Defensive Documentation Documentation – The right way! Chronological Comprehensive Complete Concise Descriptive Factual Legally aware Legible Relevance Standard abbreviations, symbols, and terms Thorough Timely
Slide 139: Future • National Standards
Slide 140: Professional Liability Coverage http://www.nso.com/customer/faq_cov.php Does having my own individual professional liability insurance policy make me a more likely target for a lawsuit?
Slide 141: Professional Liability Coverage Why do I need an individual professional liability policy? Won't my employer's insurance coverage protect me?
Slide 142: Case Study “Mock Trial” • Judge & Jury
Slide 143: Examples • • • • SOB / Difficulty Breathing Chest Pain Low BP / Change in LOC Lungs “wet” – IVF wide open
Slide 145: References 1. 2. 3. 4. 5. 6. 7. Ashley, Ruthe C. “Legal Counsel.” Critical Care Nurse, Dec 2004 Charting Made Incredibly Easy. 2nd Edition. Lippincott Williams & Wilkins: Philadelphia, Pennsylvania, 2002 Feutz-Harter, Sheryl. “Nursing Case Law Update: Faulty Documentation.” Journal of Nursing Law, Vol.2 Issue Mary E. O’Keefe, Nursing Practice and the Law (Philadelphia: F.A. Davis Company, 2001), 140–41. Medi-Smart Nursing Education Resources: “Nursing Legal Issues” http://www.medi-smart.com/documentation.htm North Carolina Board of Nursing: http://www.ncbon.com/ Nurses Service Organization: www.nso.com