Documentation For Nursing Professionals Todays Objectives Increase awareness

Documentation For Nursing Professionals

Today’s Objectives Ê Increase awareness of documentation risks, specifically targeting exposure to negligence and malpractice claims. Ê Enhance the quality of documentation by expanding awareness in order to provide quality patient care and avoid malpractice incidents. Ê To address the documentation steps in order to implement, and thus help protect your patient from harm and minimize your liability exposure.

Importance of Documentation Ê Legal Ê Reimbursement Ê Research Ê Communication and Quality Improvement

What is Malpractice? Ê Definition: Negligence or failure to provide the degree of care required of a professional under the scope of license resulting in injury, death or damage. Ê Malpractice is a type of negligence that pertains to professionals. Ê Nurses and other professionals can be sued for malpractice.

What is Malpractice? Duty Breach Cause Harm

Remember: The Patient Healthcare Information Record is a Legal Document. Ê The record must reflect accurate and contemporaneous information. Ê The patient care record documents the care provided. Ê Under state laws, the patient healthcare information record is the property of the health care provider. Ê Patient is entitled to a copy of the record under the laws of most states.

Legal Perspective Ê Not documented = not done Ê Poorly documented = poorly done Ê Incorrectly documented = potentially fraudulent

Reimbursement Ê Your documentation may influence how you and your employer are reimbursed for services rendered and can help minimize financial loss. Ê For billing purposes, documentation should include: – The actual provider – The service or services provided – The diagnosis

Research Ê The growing availability of electronic healthcare information records, and large databases of health information afford researchers a range of opportunities: – Quality/Safety Measurement – Public Health – Payment – Provider certification or accreditation – Marketing

Communication and Quality Improvement Ê Better communication across the healthcare team Ê Consistent care across providers Ê Improve healthcare delivery Ê Safeguard against potential adverse events Ê Better patient experience

Principles of Documentation Ê Characteristics of good documentation Ê Standardized terminologies Ê Notes about Electronic Health Records (EHR) Ê Do’s and Don’ts

Good Documentation: What to record Facts Observed Behavior Services Rendered

Good Documentation: What to record, contd. Results of diagnostic procedures and tests The time given, route, and patient response to medication Precautions and preventive measures used Referral and consultation requests Efforts to seek clarification

Good Documentation: Writing Style Specific Clear Complete Concise Sequential Timely Avoid generalized phrases Avoid errorprone abbreviations

Standardized Terminologies Ê Use only facility-approved abbreviations Ê Avoid error-prone abbreviations, symbols, and dose designations, such as – IU • Mistaken as “IV” or “ 10” • Write out “units” instead – U • Mistaken as “ 0” or “ 4” • Use “unit” – QOD • Mistaken as “QD” (daily) or “QID” (four times daily) • Use “every other day” – trailing zeros (ex. 1. 0) – “naked” decimal points (ex. . 5 mg)

Special Notes: Electronic Health Records Ê Patients’ privacy must be protected Ê Ensure that key patient identifiers are accurate Ê Avoid copying and pasting when documenting high-risk items Ê Do not copy and paste another clinician’s notes without proper attribution Ê Do not delete original source text or data and insert it elsewhere in the record Ê Remember: electronic healthcare information records automatically date and time each entry and identify electronic deletions, so any attempt to alter the record is apparent and can be discoverable.

Patient Privacy/HIPAA Ê Check that you have the correct chart by doublechecking patient identifiers before you enter any information. Ê Do not permit any visiting relative or other third-party access to the patient care record. Ê If provided with a laptop, electronic pad or electronic PDA, do not permit any other person access to that equipment and never share passwords/access codes

Do’s and Don’ts Do: Don’t: Ê Read and act upon progress notes of previous shift Ê Use vague expressions Ê Be specific Ê Be objective Ê Document each of your observations Ê Document complete assessment data Ê Document interventions and status of patient following any intervention Ê Record a symptom without including what you did about it Ê Use shorthand or abbreviations unless they are approved Ê Give excuses Ê Record for someone else Ê Record care ahead of time

Remember: Not Documented? Not Done.

Documentation Techniques Ê Charting by exception Ê FOCUS Ê Narrative Ê SOAP Ê SOOOAAP

Charting by Exception Ê Only document unusual events or changes in the patient’s condition Ê Activities are assumed done unless charted otherwise Ê Typically includes a checklist or flow chart nurses use to check off items to acknowledge that they were performed. Ê Sets standards for assessment and care Ê Only write out narrative when there is an exception to the standard of care.

Charting by Exception: Pros and Cons Pros Cons Ê Promotes uniform nursing practice Ê Not all stages of nursing process are evident Ê Makes abnormal trends obvious Ê Predictable, defined outcomes are required Ê Highlights abnormal data Ê Difficult to ensure completeness Ê Reduces charting time Ê Care plan isn’t always revisited Ê Preventive/wellness issues aren’t addressed

FOCUS Ê Designed to encourage a more positive perspective on patient care Ê Uses three columns: – Date/hour – Focus Enter the area of the patient’s care or condition that is being recorded – Progress notes Includes three areas for entry: • Data • Action • Response

FOCUS: Pros and Cons Pros Cons Ê Highly structured Ê Requires nurse to adjust thinking pattern Ê Promotes nursing process Ê Emphasizes evaluation Ê Requires monitoring to ensure practitioners follow up on responses Ê Flexible structure Ê Terminology can be inconsistent between notes Ê Easy for others to follow Ê Can be used in multiple Ê Progress notes may evolve into narrative format areas/disciplines

Narrative Ê Broad category, many variations Ê Chronological account of events in a free-form, sentence-based structure Ê May include columns or sections to organize information: – Treatments – Observations – Comments

Narrative: Pros and Cons Pros Ê Simplified Cons Ê Can lead to notes that are fragmented, disjointed, Ê Promotes chronological rambling, inconsistent, etc. documentation Ê Difficult to retrieve Ê Works in all clinical information/identify trends environments Ê Patient outcomes may not Ê Easy to teach/learn be consistently documented Ê Requires no special Ê Author must learn through forms experience

SOAP Stands for – Subjective observations, spotlighting the patient’s main concerns – Objective observations – Assessment of the patient – Plan of care for intervention and follow up

SOOOAAP Ê Expands on SOAP by including risk-reduction techniques Ê Includes: – Subjective information – Opinion – Options – Advice – Agreed plan – Plan of care for intervention or follow up

SOAP and SOOOAAP: Pros and Cons Pros Cons Ê Address specific problems Ê Time consuming Ê Difficult to use in a fastÊ Structure guides thought paced environment process Ê Routine care is difficult to Ê Notes organized the document same from author to Ê Frequent, repetitive charting author is necessary; problems arise Ê Problem list alerts all when not all components are caregivers used Ê Notes show continuity of care

Risk Management Strategies Ê Nurse Practice Act Ê Policies and Procedures Ê Incident Reporting Ê Quality Monitoring

Nurse Practice Act Ê Understand your state’s Nurse Practice Act Ê Be aware of changes that are made to it Ê Find your state’s Nurse Practice Act: www. ncsbn. org/npa (National Council of State Boards of Nursing) Ê Follow professional organizations and journals on social media for trends and updates to nursing practice

Policies and Procedures Be aware of your facility’s policies and procedures for documentation, including the ones specifically for: Ê Charting styles Ê Correcting errors Ê Copying and pasting in the electronic record Ê Common abbreviations Ê Incident reporting

Incident Reporting Ê Helps to reduce losses through timely, prudent, and compassionate response to incidents Ê Protects practitioners Ê Protects patients Ê Be alert Ê Report any unusual, out of the ordinary occurrences

Incident Reporting Ê It is important to know and comply with your institution’s incident reporting guidelines Ê Examples of reportable incidents include: – Patient falls – Medication errors – Equipment failure – Complaint by patient, family member, visitor – Treatment-related injuries – Missed/incorrect diagnosis – Employee exposures

Incident Reporting When writing an incident report: Ê Document only the facts Ê Report immediately Ê Do not speculate Ê Do not draw conclusions Ê Do not document impressions/opinions Ê Writing in the patient’s healthcare informational record does not take the place of an incident report, and vice versa Ê Use the patient’s healthcare informational record for clinical observations only Ê Do not mention the incident report in the patient’s healthcare informational record

Quality Monitoring Participate in investigations Maintain confidentiality of all information

Case Study

Case Study Ê A 23 -year-old woman with no significant medical history presented to the emergency room with flu-like symptoms. Ê She complained of generalized body ache and had a fever of 102. 6. Ê For the past two weeks, she self administered over-the-counter medications with no relief. Instead, her condition deteriorated and she developed both shortness of breath and a cough. Ê Her worsening symptoms motivated her to seek care a local emergency room.

Case Study Ê Test results showed: – an abnormal CT Scan of the chest (near-complete collapse of right upper lobe, large consolidation of the right lower lobe, and moderate consolidation of the left lower lobe of the lungs) – an elevated white blood count (19, 500) – abnormal liver function tests – an abnormal coagulation profile Ê The emergency department physician admitted the patient to the intensive care unit under the care of an attending physician. Ê The patient was started on oxygen and antibiotic therapy. Ê Blood cultures were drawn and showed Streptococcus Pneumoniae and antibiotics were appropriately adjusted per recommendation of the infectious disease specialist.

Case Study Ê The attending physician first saw the patient in the intensive care unit. Ê At the time of his initial exam, the patient was not in significant respiratory distress, was responding well to the oxygen and antibiotic therapy, and was subsequently continued on the same therapy. Ê The attending physician noted that while the patient was not in acute distress, her blood chemistry was abnormal with a potassium level of 2. 9 (normal range is 3. 5 to 5. 0). Ê The physician ordered 30 m. Eq of potassium to be added to each bag of the patient’s intravenous fluid, infused at 80 milliliters per hour. Ê The order was to be maintained through the remainder of her course of treatment.

Case Study Ê Two days later and despite the potassium added to her intravenous fluids, the patient’s potassium level was noted to be 3. 0 and the attending physician ordered 80 m. Eq of potassium to be administered by mouth. Ê The patient vomited the medication (amount retained undetermined). Ê The attending physician then ordered two doses of 40 m. Eq of intravenous potassium to infuse over a four hour time period with the plan of increasing the potassium level between 4 and 4. 5. Ê Documentation is problematic. Ê It appears that despite the order for two doses of potassium 40 m. Eq to be infused over four hours, the intensive care unit nurse administered two intravenous potassium doses of 20 m. Eq over approximately one hour (documentation regarding this is inconclusive).

Case Study Ê Throughout the day the intensive care unit nurse documented the patient’s heart rate in the patient care record. At 7: 30 a. m. it was 72 beats per minute, at 1: 30 p. m. it was 96 beats per minute and at 4: 30 p. m. it was 116 beats per minute. The patient’s blood pressure remained stable at 120/80. Ê The intensive care unit nurse did not specifically notify the physician of the pattern of rising heart rate. Ê When the physician saw the patient that day, he noted that the patient’s vital signs were within normal range, and her white blood cell and platelet counts remained higher than normal but were dropping. Ê He ordered a pulmonary consult for possible bronchoscopy but deemed that she was stable, and that vasopressors and aggressive pulmonary treatment were not necessary. Ê He ordered the patient to be transferred to the telemetry unit.

Case Study Ê The intensive care nurse’s documentation fails to provide the exact time of transfer from the intensive care unit to the telemetry unit although it appears to have been between 7: 15 p. m. and 7: 30 p. m. Ê The documentation also fails to validate the intensive care nurse’s statement that the patient was on a cardiac monitor during her intensive care stay and that she was transferred to the telemetry unit with a cardiac monitor and oxygen therapy. Ê The telemetry unit nurse stated the patient did not arrive with a monitor. Other telemetry unit staff indicated that the telemetry unit was in an overflow situation when the patient was transferred and the central monitoring station was not functioning. Ê Regardless of the actual reason, there are no telemetry unit electrocardiogram strips for this patient.

Case Study Ê According to hospital records, the attending physician was called at approximately 10: 00 p. m. and was advised that the patient had gone into cardiac arrest. Ê The on-call emergency physician attempted to resuscitate, but was unable to obtain a heart beat and the patient was pronounced dead.

Discussion Ê Do you believe the nurse was negligent? Ask yourself: – Did the nurse have a duty to the patient? – Was there a breach of that duty? – Is there causal connection between the breach of duty and harm? – Were there any damages to the patient? Ê Do you believe that any other practitioners or parties were negligent? Ê Do you believe that an indemnity and/or expense payment was made on behalf of the nurse? Ê If yes, how much?

Case Study Ê The family of the deceased sued the attending physician, the hospital and three of the hospital’s registered nurses, and sought $3, 000 in damages. Ê The allegations against the intensive care unit nurse included: – alleged failure to properly administer the medications as ordered by the physician – failure to notify the attending physician of significant changes in the patient’s vital signs and laboratory results

Case Study Ê Initially, the defense team felt the intensive care unit nurse had a strong case. Ê She stated she had done nothing wrong. Ê She indicated that she did not believe that she had enough experience and should not have been working in the intensive care unit. Despite her limited clinical skills, she believed she followed the physician’s orders appropriately and documented her actions thoroughly. Ê She recalled administering the potassium and believed she had advised the physician when necessary. Ê She further believed she had properly documented her actions throughout her care to the patient.

Case Study Ê When an expert witness examined the case, he noted that the intensive care unit nurse administered an incorrect dosage of medication over a shorter period of time. Ê The expert also noted that nursing protocols required that the discharging intensive care unit nurse should have specifically noted the time of transfer, the patient’s condition at that time, the patient’s current treatment, the patient’s response to treatment and the specific equipment transported with the patient. Documentation of these items is inadequate or missing. Ê The intensive care unit nurse’s notes suggested that the patient’s heart rate had increased at an alarming rate that day and this should have resulted in the nurse calling the attending physician to assess the impact of the patient’s rising pulse on the transfer and medication orders.

Case Study - Outcome Ê The expert witness stated the intensive care unit nurse’s care and treatment of the patient was not medically defensible Ê The claim against the intensive care unit nurse settled at mediation for $100, 000 with an additional $6, 152 in legal expenses. Ê The total settlement amongst all of the defendants in the case was $1. 4 million.

Case Study Risk Management Comments Ê The intensive care unit nurse failed to notify the physician that the patient’s heart rate was continuing to rise. She failed to follow the physician’s medication orders by administering an incorrect dosage of potassium at an incorrect rate. She then failed to properly document her actions. Ê The intensive care unit nurse also failed to provide a full report to the telemetry unit nurse at the time of transfer and during the handoff process, including the information that the patient required oxygen and was on continuous monitoring. Ê The intensive care unit nurse indicated to her attorney that she believed she did not possess the clinical skills to work in the intensive care unit but there is no information as to whether she requested a change in assignment, a mentor or close supervision by a trained intensive care nurse.

Case Study Risk Management Comments Ê The handoff process between the intensive care unit nurse and the receiving telemetry unit nurse was improper because it did not include the following: – reconciliation of medications ordered and administered – report of the patient’s rising heart rate – results of ordered laboratory tests – list of outstanding test results – notification of whether the physician was made aware of the vital signs – change in the patient’s general condition Ê There is no documentation to verify that the patient was transferred with a cardiac monitor and oxygen via nasal cannula as ordered.

Case Study Risk Management Recommendations If the nurse’s training and experience have not provided the nurse with the skills necessarily for performing roles specific to a new clinical area, it is the responsibility of the nurse to: Ê Notify the charge nurse and/or supervisor that the assigned clinical area is outside the nurse’s training and experience. The nurse should explicitly note his/her lack of training and experience in that area/specialty and request an alternate assignment. Ê Request close supervision and/or the assistance of an experienced nurse if the assignment is not changed and request all treatments and medications be checked prior to administration. Ê Obtain assistance for lack of complete understanding of any aspect of the patient’s condition, plan of care, progress notes, physician orders and/or medication orders. Ê Utilize the chain of command, including the director of nursing and/or hospital administrator, until provided with an assignment appropriate to his/her level of training and experience or that appropriate support and supervision with an experienced nurse is provided.

Case Study Risk Management Recommendations Ê Monitor and document the patient’s vital signs, symptoms, response to treatment and changes in condition in the patient care record. Ê Timely report all significant findings to the patient’s physician. Ê Adhere to physician medication orders including the correct drug, dosage, route and administration times. Ê Contact the physician and/or pharmacist with questions, concerns or to obtain clarification regarding the medication(s) ordered for the patient. If the physician does not respond in a timely manner, follow the chain of command to the point of resolution. Ê Manage any deviation from the physician’s order regarding administration of a medication as a medication error including reporting, investigating and developing a plan of correction to prevent subsequent recurrences. Ê Perform and document formal handoff procedures when transferring a patient and report all significant patient information regarding the patient’s treatment, including a review of treatments, tests, medications and outstanding orders, to the accepting nurse.

Review

Review A well-documented healthcare information record: Ê Protects your patient Ê Demonstrates that you are a competent nurse to: – Board of Nursing – Medicare – Other stakeholders and third parties Ê Minimizes the potential of being named as a defendant in a lawsuit Ê Greatly assists with your defense if you are named in a lawsuit

Review Do Ê Read and act upon progress notes of previous shift Ê Be specific Ê Be objective Ê Contemporaneously record patient care Ê Document each of your observations Ê Document complete assessment data Ê Document interventions and status of patient following any intervention Ê Record each telephone call or conversation with any member of the patient’s treatment team, including the exact time, message, and response

Review Don’t Ê Write imprecise descriptions. Ê Use excuses, opinions, or subjective statements. Ê Copy and paste without proper attribution. Ê Record care ahead of time Ê Use shorthand or abbreviations unless they are included in the approved abbreviation list. Ê Write anything in an email, text message, or other electronic message that you would not be comfortable including in the patient’s healthcare information record.

Review Ê HIPAA and Patient Privacy – Speak quietly when in public areas, and avoid using patients’ names – Keep file cabinets or records rooms locked – Use secure passwords, and regularly change your passwords – Be aware of and report any suspected security breaches Ê Practicing Competent Nursing – Understand your state’s Nurse Practice Act – Comply with policies, procedures and regulatory requirements – Seek additional educational opportunities Ê Incident Reporting – Report any unusual, out of the ordinary occurrences to your risk manager – Report an incident to your insurance provider – if you have your own policy Ê Quality Monitoring – Participate in investigations – Maintain confidentiality of all information

Questions?

Disclaimer Ê The purpose of this presentation is to provide general information, rather than advice or opinion. It is accurate to the best of the speakers’ knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional and legal counsel. In addition, Affinity Insurance Services, Inc. (AIS), Nurses Service Organization (NSO) or Healthcare Provider Service Organization (HPSO) do not endorse any coverage, systems, processes or protocols addressed herein unless they are produced or created by AON, AIS, NSO, or HPSO, nor do they assume any liability for how this information is applied in practice or for the accuracy of this information. Ê Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and AON, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. To the extent this presentation contains any descriptions of CNA products, please note that all products and services may not be available in all states and may be subject to change without notice. Actual terms, coverage, amounts, conditions and exclusions are governed and controlled by the terms and conditions of the relevant insurance policies. The CNA Professional Liability insurance policy for Nurses and Allied Healthcare Providers is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA Company. CNA is a registered trademark of CNA Financial Corporation. © CNA Financial Corporation, 2017. Ê NSO and HPSO are registered trade names of Affinity Insurance Services, Inc. , a unit of Aon Corporation. Copyright © 2017, by Affinity Insurance Services, Inc. All rights reserved.