Nursing documentation is an essential aspect of nursing and can protect you in cases of litigation

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