IMPLICATIONS OF DOCUMENTATION IN NURSING

Presented by Sophia Smith U.H.W.I. NURSING STAFF DEVELOPMENT DIVISION

S.L.Smith

Charting with a jury in mind

S.L.Smith

IMPLICATION OF DOCUMENTATION IN NURSING

YOU WAKE UP in a cold sweat after dreaming that youre the defendant in a medical malpractice case. The plaintiffs lawyer was about to point out the flaws and gaps in your documentation. Thankful it was only a dream.

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OBJECTIVES
At the end of this ninety (90) minute session participants will be able to:

Define the terms documentation, record, report and client. Indentify the reasons for documentation. Discuss the principles of documentation. Describe 2 societal factors that affect legal documentation

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OBJECTIVES

Discuss the nursing implications of documentation. Identify measures to ensure documentation meet legal standards.

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DEFINITIONS

Documentation is any written or electronically generated information about a client/ patient that describes the care or service provided to that client (CRNBC, 2007).

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DEFINITIONS

Record is the information set down in writing. Report is spoken or written account. Client refers to individuals, families, groups, populations or entire communities who require nursing expertise.
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REASONS FOR DOCUMENTATION

To facilitate communication To promote good nursing care To meet professional and legal standards

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PRINCIPLES OF DOCUMENTATION IN NURSING.

Accuracy : - Entries must be accurate. Write only observations that you have seen, heard, smelled, or felt. - An observation made by others must be clearly indentified . - Check the spelling, proof read.
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PRINCIPLES OF DOCUMENTATION IN NURSING

- Avoid use of abbreviations (other than those approved and documented in the organizational policy).

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PRINCIPLES OF DOCUMENTATION IN NURSING

Completeness : -be factual, accurate, true and honest record. (including record of late entries, changes or additions). -avoid duplication of information.

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PRINCIPLES OF DOCUMENTATION IN NURSING

Conciseness: - documentation contain meaningful and relevant information. - include detailed documentation in relation to critical incidents.

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PRINCIPLES OF DOCUMENTATION IN NURSING

Objectivity: - When charting subjective findings identify the source. Organization: - Each entry must clearly show a logical and systematic grouping of important information
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PRINCIPLES OF DOCUMENTATION IN NURSING

Timeliness: - Documenting in a timely manner can help in reducing errors. Legibility: - Writing must be clear and easily read by others.
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PRINCIPLES OF DOCUMENTATION IN NURSING

Confidential: - access to client information should be to health team persons who are caring for the client.

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PRINCIPLES OF DOCUMENTATION IN NURSING CONTD

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IMPLICATION OF DOCUMENTATION IN NURSING

Societal factors that affect nursing documentation include:

Increased Consumer Awareness. Increased Acuity of Hospitalized Patients. Increased Emphasis on Outcomes.

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IMPLICATIONS OF DOCUMENTATION

Failure of adhering to the principles of documentation may be detrimental to the patient and thus result in legal nursing issues.

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MEASURES TO ENSURE DOCUMENTATION MEET LEGAL STANDARDS

Documenting assessment of the needs. Documenting purpose, objectives or expected outcomes Documenting the plan or approach to care. Evaluation of interventions and outcomes
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IMPLICATIONS OF DOCUMENTATION

If you are ever involved in a malpractice dispute, the patients chart will be your best friend or your worst enemy.

So ensure each entry is:

Factual Accurate Complete Timely

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Finding Flaws in the Record

Looking for red flags in the record

Pages without any patient identification Notes written with the wrong date or with times An entry written over a previous entry to correct or change it Changes in slant, uniformity, or pressure of handwriting or changes in ink or pen on the same entry.

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Finding Flaws in the Record

Looking for red flags in the record

Any erasure or obliterations Pathology report or diagnostic test findings that don't correlate with physical assessment findings or that don't show the medical necessity for a procedure. Long narrations that don't seem to be sequential.
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IMPLICATIONS OF DOCUMENTATION GROUP WORK 5 minutes

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Failure to notify the health care provider of problem. The patient Matilda Bennetts condition was worsening. Her nurse called the attending physician several times to report the deterioration but failed to document her initial unsuccessful attempts to reach the physician. In a deposition, the nurse testified that shed called the physician as soon as she noted a change in Ms. Bennetts condition.

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Her nursing documentation indicated that the patients condition changed for the worse at 2:40 p.m., but an attempt to contact the patients physician wasnt documented until 3:45 p.m. The attending physician corroborated the nurses testimony, saying that hed received a call from her at 3 p.m., but the jury refused to overlook the lack of documentation
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Failure to notify the health care provider of problems Scenario

IMPLICATIONS OF DOCUMENTATION

No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility if you're ever involved in a lawsuit.

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Reference
Austin, S. (2006). Ladies and gentlemen of the jury, I present the nursing documentation. Retrieved on March 17, 2011 from http://www.nursingcenter.com/prodev/ce articleprint.asp?CE_ID=622257

Bergerson, S.R. (1988). More about charting with a jury in mind. Nursing, 18(4), 50-8.
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Reference
Carven, R. F. & Hirnle, C. J. (2007). Fundamentals of nursing: human health and function. (5th ed.). Philadelphia: Lippincott Williams & Wilkins.

CRNBC. (2003). Nursing Documentation. Retrieved on June 8, 2009 from http://www.crnbc.ca/downloads/151.pdf

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THANK YOU.

ANY QUESTIONS.

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