Nursing Documentation
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Nursing documentation is a critical legal and professional responsibility for nurses. It provides evidence of the quality of care delivered, ensures continuity of care between providers, and can be used in litigation to establish if the standard of care was met. Nurses have a duty to maintain complete and accurate records of all care provided, and documentation should be done contemporaneously according to hospital policies to be considered credible evidence. Thorough documentation encompasses assessments, nursing diagnoses, treatments, medication administration, communications with other providers, and patient responses. Following standards for objective, legible documentation can help reduce nursing liability.
Nursing Documentation
- 1. Nursing DocumentationNursing Documentation Author: Meredith Scannell, RN, CNM, MSN, MPH
- 2. “If it wasn’t charted, it wasn't done”
- 3. DocumentationDocumentation • Nurses have a duty to maintain complete and accurate recording of all the care thy provide. • Nurses working in specialty areas have greater risk for litigation exposure. • Complexities of care patients require more documentation
- 4. DocumentationDocumentation • The medical record is a legal document required by state laws and regulations. • Medical records are scrutinized by members of the litigation team. • Considered as important as testimony in courtroom. • Most important piece of evidence in a lawsuit alleging negligent practice.
- 5. DocumentationDocumentation • May be handwritten • May be electronic • Combination
- 6. DocumentationDocumentation • Other uses for medical records: -Education - Research - Substantiate reimbursement/insurance claims. • Can be used as legal evidence in litigation cases to establish if standard of care was met.
- 7. DocumentationDocumentation • Nurses are considered clinicians • Role is not limited in the care of patients and in past years there has been a paradigm shift. • Profession judgment • Highly skilled • Educated professions • Care delivered based on making clinical decisions based on assessments.
- 8. DocumentationDocumentation • Risk exposure includes • Assessment • Communication a change in patient condition • Initial and subsequent nursing diagnosis • Interpretation of diagnostic findings • Treatments • Changes in treatment plans • Medication adminstration and dosing
- 9. DocumentationDocumentation • Purposes • Ensuring quality of care through communication • Legal evidence of the continuity of care • Legal evidence of outcome of care • Assist in establish stands of practice • Provide a database for trending outcomes
- 10. Safe DocumentationSafe Documentation • Follow hospital/agency policy • Failure to follow policy can result inconsistencies and appear non-credible in a court of law. • Follow policies in how to make late entries.
- 11. ““The palest ink is betterThe palest ink is better than the strongestthan the strongest memory”memory” -Chinese proverb-Chinese proverb
- 12. Safe DocumentationSafe Documentation • Accuracy is critical • Contemporaneously “chart as you go • If ignored for too long, most likely forgotten • The higher the patient acuity the more frequent documentation. • Document conversations with other healthcare providers • Document nursing interventions before and after notifying another healthcare provider
- 13. Safe DocumentationSafe Documentation • Hospital/agency policy are not laws. • Used as standards that should have been followed. • Used as standards that were met.
- 14. Safe DocumentationSafe Documentation • Documentation based on Standards of Practice for Registered Nurses when documenting information. • Defined by state and federal laws. • Nurses Practice Acts: specific state requirements that nurses shall be responsible and accountable • Specific Standards from Association of Women’s Health, Obstetric and Neonatal Nurses, The National Association of Neonatal Nurses. • Federal and state organizational standards; The Joint Commission, Centers for Disease Control
- 15. Safe DocumentationSafe Documentation • Patients name is on every page • Everything must be legible • Late entry • Maintain objectivity and not opinions
- 16. Safe DocumentationSafe Documentation • Chronology of events • Date and time of entry • Patient history • Interventions • Observations • Outcomes • Patient and family responses • You signature and credentials
- 17. Safe DocumentationSafe Documentation • Educational material given • Understanding of educational material • Referrals • Consents • Discharge plan • Follow up • Telephone calls (providers and family)
- 18. Documentation Don’tsDocumentation Don’ts • Do not use the medical records as a battleDo not use the medical records as a battle groundground • Do not blame and individual or departmentDo not blame and individual or department • Limit finger pointing and focus on problemLimit finger pointing and focus on problem solvingsolving • DoDo not chart opinionschart opinions
- 19. The EndThe End
Editor's Notes
- #8: Â As nurses are named as defendants in medical malpractice lawsuits more frequently, their documentation comes under greater scrutiny.