Professional Documents
Culture Documents
Key Points . . .
New technology offering different ways to record, deliver,
and receive patient records (e.g., facsimile, telephone, email, computer charting) poses serious documentation and
legal issues for nurses.
Nurses must be knowledgeable about the risk factors associ-
tion are more likely to provide an accurately documented patient record and, as a result, better patient care.
phone conversations. The demand for oncology nurses involved in these activities can leave a paper trail that would take
others months, or even years, to follow and understand. Nurses
need to understand the laws as they apply to documentation
and be familiar with the issues that have a substantial impact
on their nursing role.
Adding the increased use of and reliance on technology in
the nursing setting complicates matters even further because liability can result from the nurses improper documentation
when using these new technologies. Changing technology is
stretching the parameters of documentation and the concerns
related to adequately documenting care. Fortunately, oncology
nurses can do several things to ensure effective patient care
and proper documentation.
This article discusses the various methods and forms of
documentation used by nurses and provides guidelines for the
proper documentation of a patients chart. Reasons why some
nurses do not adequately document care also are discussed.
The article focuses specifically on the widespread use of
emerging technology and its impact on patient charting and
Marilyn Frank-Stromborg, EdD, JD, ANP, FAAN, is the chair and
presidential research professor in the School of Nursing, and
Anjeanette Christensen, BA, and David Elmhurst Do, BS, are thirdyear law students in the College of Law, all at Northern Illinois University in DeKalb. (Submitted January 2000. Accepted for publication September 13, 2000.)
Advantages
Disadvantages
Documentation by exception
Reduces paperwork
Less time consuming
Reduces repetition of charting
Provides immediate identification of changes
in patients condition
Nurse does not look negligent for anything not
documented.
Documentation by inclusion
Very time-consuming
Creates additional paperwork
Technology
With the ever-increasing advancements of technology come
different ways to record, deliver, and receive patient records,
which often raises patient confidentiality concerns. Confidentiality is a legal and ethical issue for nurses. It is a part of the
American Nurses Associations (1985) Code of Ethics and
appears in patients bill of rights (Nurses Service Organization
[NSO], 1999). According to these documents, nurses are expected to perform assessments and treatments discreetly and
to treat all communications and records as confidential (NSO).
Nurses in all settings should take special considerations into
account when using new technology that includes facsimile
(fax) machines, computers, and telephones.
Fax
Breaches of confidentiality exist when a nurse uses a fax
machine in an area that is not limited to the individuals access (Aiken & Catalano, 1994). Problems that can occur
from using a fax machine include the transmission of confidential information to the wrong person or receiving the information from the wrong person or the wrong facility. This
can occur by simply misdialing the fax number. A nurse who
misdials a fax number when sending information probably
will be unable to track down where the message was sent. If
the sender is able to find the receiver of the information, the
damage has been done because the confidential information
already is disseminated. To find out where a fax was sent, a
nurse must check the fax machines internal log. If the information went to the wrong number, the nurse must send another fax to that number asking the recipient to destroy the
material (NSO, 1999).
Nurses should refrain from faxing information that is highly
confidential, such as HIV and HBV tests or status reports
(Aiken & Catalano, 1994). A member of Congress had her
medical records unintentionally faxed to the New York Post the
night before her primary, and the New York Post proceeded to
publish the details about a prior suicide attempt (Jurevic,
1998). If possible, mailing information might be a better alternative to protect a patients confidentiality.
Policies and procedures must be developed regarding the
types of information that can be faxed. Although these problems cannot be completely eliminated, nurses can take safety
measures. The American Health Information Management
Association recommends that nurses first check to be sure that
the fax number is correct before dialing, check again on the fax
machine display, and check once again before pressing the
send button (NSO, 1999). The association also recommends
that nurses do the following.
Ask the recipient to send a return fax verifying receipt of the
information.
Call the place of delivery to let someone there know material is being sent and to confirm that it was received.
Always fill out a cover sheet before sending it with the information that is to be faxed.
The cover sheet should indicate if the information is confidential.
A doctors orders received by fax should be verified according to hospital protocols. In the absence of guidelines,
Telephone
Telemedicine is changing the healthcare-delivery system,
and its rapid expansion is raising questions regarding the application of traditional legal principles to the system (Granade,
1997). Nurses who use the telephone to take orders or give
patients instructions should be aware of the concerns that may
arise and should know how to effectively address them. Nurses
who treat patients with cancer, particularly in the outpatient
setting, need to be careful because patients frequently will call
in with problems caused by chemotherapy and radiation treatments. Some hospitals prohibit telephone orders related to
dangerous medications such as chemotherapy (Fiesta, 1994).
A seemingly simple request, like a prescription renewal, can
pose serious risks both to the patient and the nurse handling
the call. For example, a 55-year-old woman with a history of
taking estrogen for several years calls and requests a prescription renewal. The medication could be renewed without a chart
review if the caller was a long-time patient in the practice.
However, an actual chart review reveals that she has not had
a mammogram for three years because, although the mammograms had been ordered, the woman has cancelled every
appointment (Meiner & Steele, 1999). Because of the potential for danger when medication orders are communicated over
the telephone, orders must be written and cosigned according
to the hospital policy and procedure (Aiken & Catalano,
1994).
Another problem that can occur involves obtaining a telephone order for a do not resuscitate (DNR) order on a patient. If a controversy develops regarding the death of a patient
who has a DNR order, the nurse may be held liable if the physician states that he or she never gave such an order and did not
cosign the order (Aiken & Catalano, 1994). If a DNR order
must be obtained over the telephone, the nurse and another
witness on the telephone must sign and verify that they have
heard the DNR order given by the physician (Aiken &
Catalano).
Telephone orders should be written down immediately (see
Figure 1). Any telephone calls from other members of the
healthcare team also should be written in the record (Meiner
& Steele, 1999). Sometimes when taking telephone orders, the
connection is not always clear, which may cause words to fade
out or be misunderstood. When the nurse on the telephone
cannot clearly interpret the spoken word, he or she should repeat the name of the drug or dosage that was heard (Karch &
Karch, 1999). The nurse also should ask the prescriber to spell
the name of the drug and ask for the drugs indication (Karch
& Karch).
Not only are nurses obtaining orders via telephone, but they
also are communicating medical advice that way. Briggs
(1997) described telephone triage as a systematic process that
screens the callers symptoms for urgency and advises the
caller when to seek medical attention based on the severity of
the problem described. This process involves the careful assessment, diagnosis, plan formation, intervention, and evaluation of the patient on the other end of the phone (Coleman,
1997). A documentation diary or log sheet is necessary in each
setting where telephone triage is practiced (Meiner & Steele,
1999). Nurses should be sure to follow hospital policies and
procedures with respect to telephone triage. Nurses who conduct telephone triage should avoid asking leading questions,
using medical jargon, stereotyping callers or problems, overor under-reacting, and second-guessing the caller (Wheeler,
1993). Nurses also should talk directly with the patient, not
just to family members, give the caller plenty of time to talk
about the problem, and adequately document the call.
Lawsuits involving telephone triage have focused on the
nurses failure to provide patients with adequate warnings regarding the dangers of not complying with the advice given
(Meiner & Steele, 1999). Not following hospital policies and
procedures for conducting telephone triage, especially documentation guidelines, can have serious legal implications for
the telephone triage nurse. For example, a nurse took a call
from a patient complaining of abdominal cramping and pain
(Buppert, 1999b). The nurse told the patient that the pain was
most likely gastroenteritis but to call back in two days if the
symptoms persisted. The patient called back in two days, complaining of the same abdominal pain. The nurse who took the
second call did not obtain the patients chart before talking
with the patient. The chart would have revealed that the patient
had an intrauterine device. This nurse also told the patient that
she most likely had gastroenteritis and to call next week if the
symptoms continued. In five days, the patient went to the hospital for an office visit and was diagnosed with severe pelvic
inflammatory disease. Later, the patient needed a hysterectomy as a result of the infection (Buppert, 1999b). This unfor-
E-Mail
A discussion of recent advances in technology is not complete without including what is now probably the fastest growing form of communication: electronic mail (e-mail). E-mail
provides direct evidence of a healthcare professionals conversation (Spielberg, 1998). The e-mail message is a medical
document and should be stored electronically or printed in
hard copy and placed in the patients record. E-mail is an efficient means of communication that actually decreases time
spent answering the patients questions by telephone or in person (Spielberg). E-mail also allows for a more detailed and
considered response to the patients question or concern than
a telephone call usually permits (Spielberg). From a liability
standpoint, healthcare professionals benefit from e-mail because it accurately documents the communication. In addition,
the patient may retain these communications. Just as standard
practice requires the retention of any written notes and any
information gathered related to patient history, complaints,
diagnosis, and treatment, e-mail messages should be included
in the patients permanent file (Spielberg).
Unfortunately, the introduction of e-mail systems into a
healthcare facility also requires taking several legal precautions, such as maintaining patient confidentiality, ensuring the
patients right to informed consent, maintaining the components of a medical record, and addressing customary usage and
practice standards, state licensing, and product endorsement
(Spielberg, 1998). E-mail security echoes other modern communication technologies, such as fax machines, because the
messages can be misdirected, printed, intercepted, rerouted, or
read by unintended recipients (Spielberg). An e-mail policy
should be in place to define the authorized use of the e-mail
system and define the penalties for improper use (Jurevic,
1998).
Because it is a fairly new technology within the medical
setting, e-mail requires further examination and evaluation to
develop practice guidelines for its reasonable use (Spielberg,
1998). But like other technologies that have made their way
into medical facilities, sufficient guidelines can and should be
developed, implemented, and followed by all healthcare providers who use electronic systems to preserve patient interests
and to avoid liability. Like a doctor's orders received by fax,
Computer Charting
Computer charting is fast becoming the norm in most hospitals. Electronic or computer documentation is used in varying degrees in many healthcare-delivery systems (Brent,
1997). The advantages of using electronic documentation over
handwritten charting include more accurate and timely charting, easy access to patient information, a more efficient
method of communicating, help with providing patient confidentiality, and more legible patient information (Aiken &
Catalano, 1994). Using computers for documentation of patient care also overcomes the lack of a standardized nursing
language. By having clinical languages built right into the
computer system or having templates that allow the addition
of language systems (Utz, 1998), nurses avoid using imprecise
terms when describing patient symptoms and treatment.
Computer documentation has been shown to be very beneficial to the healthcare systems that use this advanced technology. The University of Iowa Hospitals and Clinics implemented an online documentation system for patient care orders
that features order-generated task lists, default charting responses, computer-generated chart forms, and graphic data
displays (Prophet et al., 1998). The use of this online system
resulted in more positive user attitudes and satisfaction and
perceptions of less time completing other paperwork and more
time in patients rooms (Prophet et al.). In addition, the online
system can result in more accurate orders and overcome limitations of manual narrative and flow sheet charting by cueing
the user about what is necessary and appropriate to chart.
Computer programs are designed specifically for a particular type of patient care or healthcare setting. Some hospitals
have made use of computerized care plans. Oncology nurses
can use these plans for the treatment of a patients pain because the program includes information on different forms of
analgesia used by the pain service. The plan also allows nurses
to choose what information and guidance they require for their
patient (McArthur & Cunliffe, 1998).
Although computerized documentation has distinct advantages, it has some notable disadvantages. Some of these disadvantages include the reliance on electric outlets, limited number of terminals or access points, and lack of staff understanding computer technology (Meiner, 1999b). Most
importantly are the increased concerns about legal and ethical
issues that arise from this type of documentation. Much like
with fax machines and e-mail, nurses should be aware of confidentiality concerns that arise from the use of computers. The
storage of medical records on the computer and access to such
records are primary concerns (Aiken & Catalano, 1994). Electronic data cannot be locked in a file cabinet or storage room.
The computer-based record is only as confidential as the effectiveness of the electronic security system (Meiner, 1999b).
Managers should establish policies and procedures that address those concerns, including but not limited to internal and
external data sharing, monitoring and reporting of data, periodic review of the data entered into the electronic system, and
methods for the patient to provide consent for the use and release of the stored information (Brent, 1997).
Nurses should follow their facilitys procedures for computer-based documentation, such as disposing printouts and
Conclusion
Documentation is an important part of any nurses practice,
regardless of the healthcare setting. Nurses can be liable for
inadequate documentation of a patients record, like all other
healthcare professionals. The patients expectations of privacy
and confidentiality are very important issues in the healthcare
setting, especially with the ever-increasing reliance on advanced forms of technology. Nurses must follow their
facilitys guidelines for documentation practices in every aspect of care that they provide, whether in obtaining informed
consent electronically, filling out the patient chart, or taking
orders over the telephone. Nurses should insist on the highest
level of care for their patients, which means proper documentation of each patients record. Nurses must be knowledgeable
about the risk factors associated with the emerging electronic
technologies related to nursing documentation and confidentiality expectations and implement risk-reduction practices
when using these new methods of communication. Nurses who
follow exact standards for documentation, regardless of the
technology used, will be providing a complete and accurate
account of patient care, thereby reducing the chance that questions will arise regarding their documentation.
References
Aiken, T., & Catalano, J. (1994). Documentation. In T. Aiken & J. Catalano
(Eds.), Legal, ethical, and political issues in nursing (pp. 234252).
Philadelphia: Davis.
American Nurses Association. (1985). Code of ethics. Washington, DC: Author
Brent, N. (1997). Professional negligence: Prevention and defense. In N.
Brent (Ed.), Nurses and the law (pp. 7377). Philadelphia: Saunders.
Briggs, J.K. (1997). Introduction. In J.K. Briggs (Ed.), Telephone triage protocols for nurses (pp.14). Philadelphia: Lippincott.
Brooke, P. (1997). The nurse in the community. In N. Brent (Ed.), Nurses
and the law (pp. 444447). Philadelphia: Saunders.
Brooks, J. (1998). An analysis of nursing documentation as a reflection of
actual nurse work. MEDSURG Nursing, 7, 189198.
Buppert, C. (1999a). Documentation guidelines for evaluation and management services. In C. Buppert (Ed.), Nurse practitioners business, practice, and legal guide (pp. 134147). Gaithersburg, MD: Aspen.
Buppert, C. (1999b). Legal tips. NP Central [Online]. Retrieved December
10, 1999 from the World Wide Web: http://www.nurse.net/tips/legal/
lawsuit.avoidance.shtml
Coleman, A. (1997). Where do I stand? Legal implications of telephone triage. Journal of Clinical Nursing, 6, 227231.
Fiesta, J. (1994). Failing to communicate. In J. Fiesta (Ed.), 20 legal pitfalls
for nurses to avoid (pp. 118122). Albany, NY: Delmar.
Gobis, L.J. (1997). Reducing the risks of phone triage. RN, 60(4), 6163.
Granade, P.F. (1997). Medical malpractice issues related to the use of
telemedicineAn analysis of the ways in which telecommunications affects the principles of medical malpractice. North Dakota Law Review, 73,
6583.
Jurevic, A.M. (1998). When technology and healthcare collide: Issues with
electronic medical records and electronic mail. UMKC Law Review, 66,
809836.
Karch, A.M., & Karch, F.E. (1999). What did you say? American Journal of
Nursing, 99(8), 12.