Your License may depend on it!
Nelia B. Perez RN, MSN
PCU - MJCN
Taking a Poll
1. Have you been involved in a patient
complaint against your institution?
2. Do you feel like your documentation
would support you in a court of law?
A patient you cared for 9
months ago is unhappy with
the outcome and has filed a
malpractice lawsuit against
Legal Case Studies
“Duty of Care”
• Based on existence of the nurse-patient
• A legal status created when the nurse is
legally obligated to provide nursing care to
• Law will demand that the nurse perform as
a reasonably prudent nurse
Breach of Duty
Nurse’s care fell below the acceptable
Standard of Care
malpractice case – compensatory $$$
loss of nurse’s license
loss of job / ability to work
Nursing Negligence /
• Any action by a nurse that falls
below generally accepted standards
of nursing care, and causes injury to
• Even if nurses actions were only
contributing cause to the injury
Requires that there be a
reasonably close connection
between the nurse’s conduct
and the resultant injury
Nurse has a responsibility to foresee
harm before it occurs and eliminate
• Admission Screens
• Fall Risk
• Suicide Risk
Illusion of Negligence
Evidence of the truth as
to what really happened
• Suffered loss or injury through the act,
omission, or negligence of another
– Medical costs
– Loss of earnings
– Impairment of future earnings
– Past / future pain & suffering
1. Explain the importance of documentation as a
health care provider.
2. Identify the legal aspects of nursing
3. Identify the basic information that is required when
4. Describe specific issues that require
5. Discuss documentation concerns regarding faxing
6. Discuss computerized documentation concerns.
7. Discuss documentation Do’s and Don’ts.
8. Identify how the nursing process impacts nursing
9. State characteristics of reasonable documentation.
10. Explain what constitutes Nursing Malpractice
related to the role of documentation.
11. Identify common charting errors.
12. Identify the consequences of poor documentation
13. Discuss the future of documentation standards.
14. Evaluate the medical record documentation issues
in selected legal cases.
• What do you want to know?
• Client / Patient
"if it's not documented it was
To avoid litigation, health care
providers must comply with
established standards of care.
Standards of Care
• Legislation / Statutes
• Practice Guidelines
Why Is the Chain of Command
Courts have held that nurses have a duty
to question a physician’s order if it is not
consistent with standard medical
Initiation of the Chain…
– becomes concerned
– unresponsive or insufficiently responsive
– might not return a page
– tells the nurse not to call again about the
same problem, or informs the
nurse he or she will come in later
• The dose of a • The postoperative
medication is laparoscopic
excessive or cholecystectomy
inadequate. patient begins having
• IV fluid orders are symptoms of an acute
incomplete or abdominal process.
inconsistent. • The patient has widely
• The nurse is divergent intake
concerned about fetal versus urinary output.
heart rate monitoring • The patient is allergic
in a patient in labor. to the medication the
Make Documentation Easier
• The Do’s
• The Don’ts
• Correct Chart
• Reflect the Nursing Process
• Write Legibly
• Permanent Black Ink
• Complete / Concise / Accurate
Clear / Concise / Accurate
Wrong Way: Communication with
patient's family begun today to specify
the manner in which his condition is
progressing and suggest a probable
consequence of that progression.
Clear / Concise / Accurate
Right Way: I contacted Mr. Boon’s wife at
1415 hours. I explained that his cardiac
status was worsening and that he was
being prepared for a cardiac
catheterization procedure scheduled for
– Client’s response
• Precautions / Preventive Measures
– Side rails
• Nursing Procedures
– Name of procedure
– When it was performed
– Who performed it
– How it was performed
– How well the client tolerated it
– Adverse reactions
• Phone calls
• Health Care Team visits
• Don’t wait to Chart
• Client refusals
• Client’s subjective data
• Medication omission
• Late Entry
• Not Applicable
• Charting Frequency
– Facility P&P / Standards
• Approved abbreviations & symbols
• Discharge instructions
• Commonly misspelled words
• Look-a-Like / Sound-a-Like
• Triplicate / Carbonated Copies
• Altering the Record
• Adding Information
• Dating the entry
– Dates / Times conflict
• Inaccurate Information.
• Destroying records
• Unapproved Abbreviations
• Chart for someone else
• Chart Opinions
• Use Negative Language
• Use vague terms
• Chart ahead
• Misspelled words
• Incorrect Grammar
• Chart staffing problems
• Chart staff conflicts
• Chart casual conversations
Charting care that you haven't
performed is considered fraud
When you make a Mistake
• White out / Eraser
• The word “Error”
• Correct the Entry
• Sad Faces
• Leave empty lines / spaces
• Write in the margins
• Make reference to incident reports
• Use words that suggest that there is a
client’s safety risk
• Violate client confidentially
Common Charting Mistakes
• Failing to record
pertinent health or
• Failing to record
• Failing to record that
• Recording on the
Common Charting Mistakes
• Failing to document a
• Failing to record drug
reactions or changes
in the patient’s
• Transcribing orders
• Writing illegible or
Failing to record pertinent health
or drug information
The nurse neglected to record
her patient’s penicillin
allergy in the admission
Because the intern didn’t know
the patient was penicillin-
allergic, he gave the patient
a penicillin injection.
The patient, who was
incoherent and couldn’t tell
the intern about the allergy,
went into anaphylactic
shock and suffered
irreversible brain damage.
At the trial, the court found the
nurse guilty of negligence.
Failing to record nursing actions
The evening nurse notices heavy drainage from the
She checks the nurses’ notes and finds no evidence that
the dressing was changed.
She considers the amount of drainage normal for a period
of several hours.
She changes the dressing but, like the day nurse, forgets
to chart her action.
The night nurse does the same.
Is the condition getting more serious? Is the patient’s life
in jeopardy? No one knows because no one realizes
that the patient’s wound is seeping more than it should.
Failing to record that medications
have been given
A day nurse gave a patient heparin by intravenous
push just before she went off duty.
An hour later, the evening nurse saw the order for
heparin--but no indication that it had been given.
So she gave the patient the same dose.
The patient began to hemorrhage and went into
He recovered--then successfully sued the hospital.
Recording on the wrong chart
Mrs. B. Moyer and Mrs. C. Moyer were on the
Mrs. B. Moyer was being treated for severe
Mrs. C. Moyer, for acute thrombophlebitis.
Mrs. C. Moyer’s doctor ordered 4,000 units of
heparin for her.
The nurse mistakenly transcribed the heparin
order onto Mrs. B. Moyer’s chart and
administered the heparin.
Mrs. B. Moyer started bleeding.
Failing to document a
A doctor suspected that his patient, who was taking
high doses of aspirin for arthritis, had developed
So he discontinued the medication.
But the patient’s nurse forgot to record the order on
the medication sheet, and she and the other
nurses continued giving aspirin.
The ulcer bled, and the patient eventually
underwent a partial gastrectomy because her
She sued the hospital for the nurses’ negligence
Failing to record drug reactions
or changes in the patient’s
A patient complained of nausea, dizziness,
abdominal pain, and itchy skin shortly after
receiving his first 100-mg dose of
nitrofurantoin macrocrystals (Macrodantin).
His nurse wasn’t concerned, though.
By evening, after two more doses of the
medication, he was vomiting and had a high
fever, urticaria, and early symptoms of shock.
He sued his nurse for negligence.
Transcribing orders improperly or
transcribing improper orders
A doctor ordered 5 ml of atropine for a patient
on the coronary care unit.
He meant to order 0.5 ml, but he didn’t include
the zero or write the decimal point clearly.
The nurse transcribed the order as 5 ml,
although she didn’t think it seemed right.
She decided the doctor knew best and didn’t
check the dose before recording it.
Writing illegible or incomplete
To play it safe:
• Sign your full name and title
• Don’t leave blank spaces, lines, or boxes on charts
• Don’t use unapproved abbreviations
• Record every nursing action as soon as possible
• Write enough to convince the reader
METHODS (STYLES) OF CHARTING
• EXCEPTION CHARTING
• BASELINE CHARTED QSHIFT
• LENGTHY, TIME-CONSUMING
• SEPARATE PAGES FOR EACH
• USED FOR PROBLEM-ORIENTED CHARTS
• S – SUBJECTIVE. WHAT PT TELLS YOU.
• 0 – OBJECTIVE. WHAT YOU OBSERVE, SEE.
• A – ASSESSMENT. WHAT YOU THINK IS GOING ON
BASED ON YOUR DATA.
• P – PLAN. WHAT YOU ARE GOING TO DO.
CAN ADD TO BETTER REFLECT NURSING PROCESS
• I – INTERVENTION (SPECIFIC INTERVENTIONS
• E – EVALUATION. PT RESPONSE TO INTERVENTIONS.
• R – REVISION. CHANGES IN TREATMENT.
EXAMPLE OF SOAP CHARTING
• #1 ALTERATION IN COMFORT. ABDOMINAL
S – COMPLAINS OF PAIN IN RUQ
O – IS PALE AND HOLDING RIGHT SIDE
A – RECURRING ABDOMINAL PAIN
P – PUT ON NPO AND NOTIFY PHYSICIAN
• USES NARRATIVE DOCUMENTATION
• DATA – SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
• ACTION – NURSING INTERVENTION
• RESPONSE – PT RESPONSE TO INTERVENTION
EXAMPLE OF FOCUS CHARTING
• D – COMPLAINING OF PAIN AT INCISION SITE
ON LEVEL OF #7
• A – REPOSITIONED FOR COMFORT. DEMEROL
50MG IM GIVEN.
• R – (CHARTED AT A LATER DATE.) STATES A
DECREASE IN PAIN, “FEELS MUCH BETTER.”
• Similar to SOAP charting
• Both are problem-oriented
• PIE comes from the Nursing Process,
SOAP comes from a Medical Model.
SAMPLE OF PIE CHARTING
• P#1 Risk for Infection r/t IV Therapy site.
• IP#1 Checked IV Site periodocally.
• EP#1 No sign of redness and swelling on IV
CHARTING BY EXCEPTION
• USES FLOWSHEETS
• EMPHASIS ON ABNORMAL (WHAT IS ABNORMAL
FOR THIS PATIENT.
• ALTHOUGH IT MAY BE ABNORMAL FOR THE
“NORMAL” PERSON, IF IT IS ABNORMAL FOR
YOUR PATIENT ON A CONSISTENT BASIS, IT IS
NO LONGER CONSIDERED AN “EXCEPTION”.
• PASSWORD. NEVER SHARE. CHANGE
• CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.
• DATE AND TIME AUTOMATICALLY RECORDED.
• ABBREVIATIONS AND TERMS ARE SELECTED BY
A MENU PROVIDED BY THE FACILITY.
• TERMINALS ARE USUALLY EASILY ACCESSIBLE,
IN PT ROOMS, CONVENIENT HALLWAY
• MAKE SURE TERMINAL CANNOT BE VIEWED BY
• QUICK REFERENCE
• CHANGED AS NEEDED
• NOT PART OF PERMANENT
• YOU MUST USE YOUR FACILITY’S
• BE AWARE THAT A LOT OF
COMMONLY USED ABBREVIATIONS:
EG. TID, BID, QOD, HS ARE NO
LONGER ALLOWED AND SHOULD
BE CURRENTLY BEING PHASED
OUT OF YOUR FACILITY.
CHANGE OF SHIFT REPORT
• PERSON TO
• BE PREPARED
• TAPE RECORDER
• DO NOT BLAME OR ADMIT
• WHAT DID YOU DO?
• DO NOT INCLUDE
• DOCUMENT TIME/NAME OF
• DO NOT FILE IN CHART
• DO NOT WRITE “INCIDENT
• IF YOU SPILL SOMETHING ON THE CHART, DO
NOT DISCARD NOTES. RECOPY, PUT ORIGINAL
AND COPIED SHEETS IN CHART. WRITE
“COPIED” ON COPY.
• DO NOT SCRIBBLE OUT CHARTING.
• AVOID USING “ERROR” OR “WRONG PATIENT”
WHEN MAKING CORRECTION.
• FOLLOW YOUR FACILITIES POLICY.
• DO NOT ALTER CHARTING, IT IS A LEGAL
• Documentation validates Nursing Care
A high-risk patient requires complete
assessment and frequent monitoring.
Documentation – The right way!
Chronological Legally aware
Factual symbols, and terms
• National Standards
Read Case Study Summaries
Nurse-Patient Relationship: You are assigned a patient You observe an unassigned patient needing help You are in a clinical setting. You take a telephone call seeking advice or you give advice to anyone who asks You observe a patient receiving inferior care from other caregivers
Proof? The act that caused injury was exclusively in the nurse’s control The injury would not have happened in the absence of the nurse’s negligence No negligence on the patient’s part contributed to the injury Evidence of the truth as to what really happened is unavailable
Two nurses were assisting a stroke patient to the sun room. Upon reaching the destination, one nurse let go of the patient to place a chair for the patient to sit. The patient fell and broke his hip. The Court said the nurses should have been able to foresee the need for a chair in place before moving the patient to the destination
Documentation……………How does the story read?
So what is the cost?
What do you want to know….. Submit your questions and we will review them at the end of the day to make sure we have answered them all
Who Cares? A. State Regulations B. Federal Regulations C. Client History D. Reimbursement Issues E. Protection at Litigation
The old saying "if it's not documented in the medical record it was not done" state and federal governments continue to enact legislation to protect various healthcare consumers. Consider the increased interest in the elderly that occurred in the late '80s and early '90's. As a result, legislation and regulations emerged relating to long term care facilities and new litigation (lawsuit) possibilities occurred. Proper documentation reflects the quality of care that you give to your clients and is evidence that you acted as required or ordered.
Standards of care arise from: Regulations based on state and federal legislation or statutes. Regardless of the term used, they are the law. 2. Practice guidelines, such as the American Health Care Association Long Term Care Guidelines Facility policies/procedures Expert witnesses
When a nurse assumes the "duty of care", the law will demand that the nurse perform as a reasonably prudent nurse would. Acting as a reasonably prudent nurse is considered conforming to a "standard of care". The standard of care, when applied to nursing, consists of nurse being expected to possess and use the knowledge, skill, care, and diligence ordinarily possessed and employed by members of the nursing profession.
This could be interpreted to mean that nurses must know when a physician’s action or inaction jeopardizes a patient’s safety and well-being. This places a significant responsibility on the nurse.
Issues arise when the nurse becomes concerned about the patient’s well-being and the physician is unresponsive or insufficiently responsive. The physician might not return a page, tells the nurse not to call again about the same problem, or informs the nurse he or she will come in later Responses convey a lack of concern for the patient and indicate a lack of respect for the nurse’s judgment . Give Scenario…..
The nurse must have a high degree of knowledge and wisdom, as well as discernment, in weighing the needs of the patient against the potential consequences of initiating the chain of command. It is not a method for exercising a personal agenda or settling a grudge against a physician. In order for this procedure to remain a valuable resource, it must be utilized with the utmost care and discretion. To do otherwise calls the professionalism of the nurse into question and jeopardizes his or her reputation.
How about Do's and Don'ts for Charting. Let’s do the Do's first, okay?
Check that you have the correct chart before you begin writing. Correct ID labels *Make sure labels on original & carbon copies* Make sure your documentation reflects the nursing process and your professional capabilities. Write legibly. Use a permanent black ink pen... other colors do not Xerox well. Chart completely, concisely and accurately ("Tell it like it is.")
Write clear sentences that get right to the point. Use simple, precise words. Don't be afraid to use the word "I."
Chart the time you gave a medication, amount, the route you gave it and the client's response Chart precautions or preventive measures used, such as bed rails. Example of how to document a med…..
What procedure was performed When it was performed Who performed it How it was performed How well the client tolerated it Adverse reactions to the procedure, if any
Record each phone call to or from a physician, including the exact time, message, and response Chart what you feel is important data from visits by physicians or other members of the health care team such as the dietician, social worker, etc. Chart as soon as possible after giving care; don't wait to chart until the end of your work day. Chart a client's refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client's physician. Chart client's subjective data (what the client perceives and the way they express it) by directly quoting it. This is the one time you can use quotation marks.
If you don't give a medication, circle the time and document the reason for the omission (hospital policy) – eMAR Non-admin reasons If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry or addendum." Include the date and time of the late entry. If information on a form such as a flow sheet doesn't apply to your client, write NA (not applicable) in the space provided. Chart often enough to tell the whole story.
Use only commonly used or approved abbreviations and symbols - Stedmans Document discharge instructions including any referrals to home health agencies and other community providers as well as any patient teaching that was done. Refer to the list of commonly misspelled words or confusing words , especially terms and medications, regularly used in your work setting. Remember many medications have similar names but very different actions.
When documentation continues from one page to the next, sign the bottom of the first page. At the top of the next page, write the date, time and “continued from previous page.” Make sure each page is stamped with the client's identifying information.
Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a client's record...this is a criminal offense.
Here are the four (4) don'ts or "red flags" of chart altering that are to be avoided: Don't add information at a later date without indicating that you did so. Don't date the entry so that it appears to have been written at an earlier time. Don't add inaccurate information. Don't destroy records.
Don't use shorthand or abbreviations that aren't widely accepted or at least not accepted in your facility. If you can't remember the acceptable abbreviation, then write out the term. Don't write vague descriptions, such as "drainage on bed" or "a large amount." Don't give excuses, such as "Medicines not given because not available."
Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and give credit to the individual who said or experienced it. Don't chart your opinions. Don't use language that suggests a negative attitude towards your client such as the words stubborn, drunk, weird, loony or nasty.
Don't be wishy-washy. Avoid using vague terms like "appears to be" or "apparently" which make it seem as though you are not sure what you are describing or doing. Don't chart ahead of time...something may happen and you may be unable to actually give the care that you've charted. Notes filled with misspelled words and incorrect grammar are as bad as those done in illegible handwriting. Information may be misunderstood if such notes end up in a court room.
Don't record staffing problems. Don't record staff conflicts. Don't document casual conversations with your colleagues.
Don't use white out or an eraser...if you make a mistake, draw a single line through the entry and write “mistaken entry” rather than “error.” The word error could seem to indicate that a mistake in care, not documentation, was made. Write in the correct entry as close to the mistaken entry as possible and sign with your first initial, last name and title Also writing "oops,” "oh no" or "sorry" or drawing a happy or sad face anywhere on a record is unprofessional and inappropriate.
No empty lines or spaces... fill in the empty line or space with a single line to prevent charting by someone else No writing in the margins. No mention of any incident / variance or accident report in the medical record ... document only the facts of an incident and never write the words "incident report" or indicate that you have filed one.
Don't use words associated with errors or ones that suggest that the patient's safety was in danger such as: "by mistake," "accidentally," “unintentionally," "miscalculated," "confusing.“ Don't name a second patient … doing so violates that patient's confidentiality. If you have to refer to a second client, do so by using the word "roommate" or the room number.
Suppose the patient has an allergy or a disease (such as diabetes, hemophilia, or glaucoma) that his caregivers need to know about. But you forget to record that on his chart. You could end up in court, as did a nurse at a large metropolitan hospital So you make sure you ask about every patient’s food and drug allergies, diseases, and chronic health problems. And record the information on the admission sheet and in the nurses’ notes. Alert other staff members to drug allergies by putting a bright label on the outside of the patient’s chart, according to hospital policy.
Record everything you do for a patient on his chart as soon as possible. Let’s say the day nurse observes heavy drainage from a surgical wound and changes the patient’s dressing. But she forgets to record the dressing change and her assessment of heavy drainage before she leaves. The usual excuse for not charting is "not enough time." Consider flow sheets that you can insert in the patient’s chart at the end of the shift. If your hospital has standard flow sheets, use them. If it doesn’t, ask for them.
Record every medication you give when it’s given--including the dose, route, and time. Both nurses made mistakes here. The first should have recorded that she’s given the dose. The second should have been suspicious when she saw the order for heparin but no evidence that it had been given. She could have: asked the patient if he’d received the medication. called the pharmacy to see if the dose had already been furnished. Look at pyxis record too…. called the first nurse at home. So always investigate when you suspect a medication may have been given but not recorded.
You can’t be too careful in any situation that might lead to confusion between two patients: same last name, same room, same condition, or same doctor. When you have two or more patients with the same name, be sure a different nurse is assigned to each patient; develop a system of flagging the patients’ names on charts and medication records. And check wristbands before you give medications.
If the patient is supposed to be taken off a medication because of its adverse effects, you need to document that order promptly. Cross-checking the doctor’s orders and the medication sheet before giving the medication would have prevented this patient’s serious complication.
Monitoring a patient’s response to treatment isn’t enough. You need to recognize an adverse reaction or a worsening of the patient’s condition, then intervene before the patient is seriously harmed. The fact that most patients don’t have adverse reactions to certain drugs shouldn’t lull you into carelessness; most drugs can cause problems in some patients who take them. So observe your patients closely, consider the possibility of adverse reactions when a patient reports new symptoms, and follow up appropriately.
If you transcribe orders on the wrong chart or transcribe the wrong dose, you can be held liable for any resulting injury. You can also be held liable if you transcribe or carry out an order as it’s written if you know or suspect the order is wrong. And you should be familiar enough with the medications, procedures, and activities you’re responsible for to know when something isn’t right. Anytime you’re unsure about a drug order, check it with the prescribing doctor and pharmacy. And if you’re sure the order is wrong, tell the doctor why you can’t administer the drug, then notify your nurse-manager. She’ll probably talk with the doctor and tell him that he’ll have to give the drug himself.
Print if your handwriting is difficult to read. Sign your full name and title somewhere on every page where you’ve charted. Don’t leave blank spaces, lines, or boxes on charts. If you don’t use the space, draw a line through it or write N/A (not applicable). Don’t use abbreviations that aren’t on the hospital’s approved list of abbreviations. Chances are someone could misunderstand your abbreviation. And years later, you may not even remember what it meant. Record every nursing action as soon as possible after you’ve finished it. Write enough to convince a reader that the patient was adequately cared for. These mistakes rarely cause lawsuits. But they can rear their ugly heads in the midst of lawsuits. Imagine your embarrassment at being called to testify and not being able to read your own handwriting or having to admit that the information recorded is incomplete. Such careful attention to charting is never a waste of time. It helps you demonstrate the good care you’ve given, saving yourself the need to defend it in court someday.
What is the lesson to be learned from this case? A high-risk patient requires complete assessment and frequent monitoring. And unless these measurements are documented, the court may not recognize that they’ve been performed. In this case the court didn’t believe the testimony of the nurse who claimed she’d checked the patient. The wife’s testimony, however, was consistent with the medical record.
we need to review our own notes to determine whether we are meeting the standard for what is considered satisfactory documentation within our respective employment facility how you chart is as important as what you chart. Therefore, chart only what you see, hear, feel, measure and count, not what you suppose, infer, conclude or think
Future may hold a national standardized medical record or chart format no matter where care is delivered. The result would be standardized documentation systems so that nursing employees would not have to learn a new or different system every time they changed jobs or transferred to a different position within the same facility. documentation would be even more accurate and complete wherever and whenever it is written.