Documentation For Advanced Practice Registered Nurses

Today’s Objectives Increase awareness of documentation risks, specifically targeting exposure to negligence and malpractice claims. Enhance the quality of documentation by expanding awareness in order to provide quality patient care and avoid malpractice incidents. To address the documentation steps in order to implement, and thus help protect your patient from harm and minimize your liability exposure. One of the objectives of today’s presentation are to increase awareness of the documentation risks that are faced by nurses on a consistent basis. This presentation will specifically focus on legal exposures to claims of negligence and malpractice. Another objectives is how to increase the quality of your own documentation by expanding awareness of ways to avoid malpractice incidents. The third objective is to address what documentation steps you can take to help protect your patient from harm and yourself from a malpractice incident. So, what is malpractice? Let’s define it. (ADVANCE SLIDE.) 2

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

You Are Judged by How You Document A well-documented healthcare information record: Minimizes the potential of a court appearance if you are named in a suit Aids in development of successful defense Helps against licensure actions Reduces the chance of criminal charges

Remember: The Patient Care Record is a Legal Document. Under state laws, the healthcare information record is the property of the health care provider A patient is entitled to request and receive a copy of the record under the laws of most states The record must reflect accurate and timely information The healthcare information record documents the care provided. You may not alter, remove, copy, or destroy a medical record A medical record or patient care record, as we’ll refer to it here, is a legal document that can be used to both help or harm the nurse in a legal setting. A patient owns the information that has been documented and is entitled to a copy of the record. Accurate & Contemporaneous recording of care contribute to its quality. Documentation is used to tell “the story” of the service provided. Documentation can also have a financial impact on you. How can documentation have a financial impact? (ADVANCE SLIDE.)

Legal Perspective on Documentation Not documented = not done Poorly documented = poorly done Incorrectly documented = potentially fraudulent 6

Basis for Reimbursement Your documentation will influence how you and your employer are reimbursed for services rendered and may minimize financial loss.

These facts should already be in the patient’s care record. Billing Include the following documentation to support appropriate billing for services rendered: the actual provider the service or services provided and the diagnosis These facts should already be in the patient’s care record.

Billing and Reimbursement The billing and reimbursement of your facility is your responsibility Be familiar with your health plan participation contracts Internally audit your facility’s documentation to determine if documentation consistently supports the code billed Monitor a sample of your collections against your charges on a monthly basis Validate that documentation has supported the appropriate coding and billing by monitoring collections

Medicare Fraud and Abuse It is Illegal to: Submit bills for services not rendered Upcode a service Unbundle services Solicit, offer, or receive a bribe or kickback Bill “non-covered” services as covered services Fail to comply with Medicare marketing rules

Medicare Fraud and Abuse Know and understand: Anti-Kickback Statute Physician Self-Referral Prohibition Statute

Medicare Fraud and Abuse: Avoiding a Lawsuit Stay current with CMS billing rules, and follow them consistently Be aware of common conditions that lead to malpractice claims Understand your facility’s billing and reimbursement system Avoid common prescribing errors

Considerations for Quality Documentation

Quality Documentation Reflects Quality Care Structured documentation typically inspires structured performance Document the Nursing Process: Assessment Diagnosis Planning Implementation Evaluation

Documentation Do’s Check that you have the correct medical record before you begin writing. Make sure your documentation reflects the clinical decision making process. Write legibly if using handwritten documentation. Contemporaneously record patient care at the time you provide it. Record the time you gave a medication, the dose, administration route, and the patient's response. Record precautions or preventive measures used, such as placing the call-bell in the patient’s reach

Documentation Do’s Record each telephone call to any member of the patient’s treatment team, including the exact time, message, and response. Document review of systems and relevant findings Include differential diagnosis Example: “c/o epigastric pain for 3 months, differential diagnosis includes but not limited to gastritis, peptic ulcer disease, pancreatitis, and cholecystitis”

Documentation Do’s – Informed Refusal Record a patient's refusal to allow a treatment or take a medication: report this to your manager and the patient's primary care provider document that the patient was informed of the risks of refusing treatment obtain the patient’s written refusal (some cases)

Documentation Do’s – Correcting Errors If you remember an important point after you've completed your documentation: record the information with a notation that it's a "late entry” include the date and time of the late entry late entries should be limited to facts that are essential to the patient’s care and treatment

Additions and Corrections: Electronic Documentation Establish polices and procedures for standardized action for additions and/or clarifications in EMR Obtain assistance from EMR experts in establishing policies and procedures Educate staff to approved EMR policies and procedures Regularly audit EMRs for compliance with policies and procedures Remind staff that all entries are automatically dated and timed to prevent contradictory dates and times

Additions and Corrections: Handwritten Documentation If you must make a late addition or correction to a patient’s healthcare information record, follow these guidelines or your healthcare facility’s protocol: Mark with one line through the item Make the notation/correction and explain why you did so Date and sign the corrected documentation

Documentation Don’ts Don't record a symptom, such as "c/o pain," without also recording what you did about it Don't alter a patient’s healthcare information record --this is a criminal offense Don't use shorthand or abbreviations unless they are included in the approved abbreviation list. Don't write imprecise descriptions Don't use excuses, opinions, or subjective statements Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't document care ahead of time

Documentation Don’ts Electronic Records Don’t overuse automatic or pre-filled entries Don’t blindly copy and paste standard entries or entries from the patient’s prior visits or between charts Do not copy and paste another clinician’s notes without proper attribution Don’t 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. Remember: Electronic records automatically date and time each entry and identify electronic deletions, so any attempt to alter the record is apparent and can be discoverable.

10 Documentation Strategies Do not erase, use “white out”, or cross out an error with more than one line Record only the patient’s statements, clinical facts, observed behavior, and health services rendered Do not criticize other healthcare providers or document your personal opinions Begin each entry with the date and time and end each entry with signature and title Example: (03/31/09 - 7:50AM - Jane Doe, BCCNS)

10 Documentation Strategies Do not leave blank spaces Record all entries legibly and in ink Avoid generalized phrases such as "bed soaked" or "a large amount" If an order is questioned, document that clarification was sought, the order discussed and resulting resolution

10 Documentation Strategies Document only your own observations and patient services rendered. Do not permit any visiting relative or other third-party access to the patient care record unless they have been granted legal authority to do so.

Communication Challenges Attributes: Factual Accurate Current Confidential APRN’s must communicate information about patients to nurses and other members of the patients’ health care team using oral reports, video or audio taping, and written reports.

Documentation Techniques Charting by exception FOCUS Narrative SOAP SOOOAAP

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

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

FOCUS Designed to encourage a more positive perspective on patient care 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 Highly structured Promotes nursing process Emphasizes evaluation Flexible structure Easy for others to follow Can be used in multiple areas/disciplines Requires nurse to adjust thinking pattern Requires monitoring to ensure practitioners follow up on responses Terminology can be inconsistent between notes Progress notes may evolve into narrative format

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

Narrative: Pros and Cons Simplified Promotes chronological documentation Works in all clinical environments Easy to teach/learn Requires no special forms Can lead to notes that are fragmented, disjointed, rambling, inconsistent, etc. Difficult to retrieve information/identify trends Patient outcomes may not be consistently documented Author must learn through 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 Expands on SOAP by including risk-reduction techniques Includes: Subjective information Objective information Opinion Options Advice Agreed plan Plan of care for intervention or follow up

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

Risk Management Considerations HIPAA and Patient Privacy Practicing Competent Nursing Incident Reporting Quality Monitoring

HIPAA and Documentation Security Rule and Privacy Rule The Security Rule Documentation standard has three implementation specifications. Time Limit (Required) Availability (Required) Updates (Required)

HIPAA and Documentation HIPAA requires covered entities to meet documentation requirements Be aware of and report any suspected security breaches Take steps to prevent patient health information from falling into the wrong hands or being inadvertently altered or destroyed Speak quietly when in public areas Avoid using patients’ names in public areas Keep file cabinets or records rooms locked Use secure passwords, and regularly change your passwords

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

Policies and Procedures Comply with policies, procedures and regulatory requirements Practice appropriate billing and coding methods Seek additional educational opportunities Follow ICD-9 CMS guidelines for documentation Follow appropriate incident reporting protocol

Incident Reporting Helps to reduce losses through timely, prudent, and compassionate response to incidents Protects practitioners Protects patients Be alert 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

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

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

Participate in investigations Quality Monitoring Participate in investigations Maintain confidentiality of all information

Case Study

Case study Patient Defendant 78 year-old female nursing home resident Hypertension, chronic anemia, chronic renal failure, congestive heart failure, morbid obesity She was on the anti-coagulant Coumadin because of atrial fibrillation Defendant Onsite NP working for outside healthcare facility via contract with nursing home Responsible to answer calls for healthcare facility and return emergent pager calls Responsible for making visits to nursing facility as needed

Case study Day 1 Attending MD (also president of the facility) ordered that the resident be started on Bactrim for bladder infection Staff questioned order because of potential for adverse effect of combining Bactrim and Coumadin Resident also took daily doses of ibuprofin Day 2 Lab tests showed no bladder infection Bactrim was not discontinued Day 6 Lab tests showed that resident’s bleeding time had increased – at risk of bleeding from Coumadin

Case study Day 8 Day 10 Resident bleeding from gastrointestinal tract NP gave orders to stop Coumadin for 2 days and recheck blood tests on Day 11 Day 10 Alleged that the NP was advised by nursing home staff of blood clots in resident’s stool NP faxed her on-call report to the medical director after each call from the nursing home NP did not keep copies of the reports or of her notes made during calls Medical director denied receiving the reports

Case study Days 9-11 Day 11 Resident continued to bleed NP, attending and medical director were notified but took no action Nursing staff notes reflect that the resident was dizzy and nauseated Day 11 Resident found dead in bed Bled to death from gastrointestinal hemorrhage

Discussion Do you believe that the nurse practitioner was negligent? Did the nurse practitioner 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? Do you believe that any other practitioners or parties were negligent? Do you believe that an indemnity and/or expense payment was made on behalf of the nurse practitioner? If yes, how much?

Case study Allegations Against NP Failure to evaluate, monitor, and treat the resident’s severe anemia and bleeding Failure to timely contact the medical director about the patient’s bleeding Exceeding the scope of practice by making medical decisions about the patient’s bleeding

Case study The Defense Argument The Plaintiff Argument NP presented as a very credible witness NP was within the standard of care for taking a telephone triage call by holding the Coumadin and ordering a follow-up INR lab level. The Plaintiff Argument NP should have obtained vital signs, medications, current problem list, past medical history and labs. Responsibility of the NP to obtain the information she needed to make an appropriate assessment and not wait for it to be offered to her.

Case study The Resolution Took 2 ½ Years to settle Settled at mediation for $450,000 plus additional $181,225 in legal expenses Healthcare facility and nursing home also settled for separate amounts. Total incurred expense for NP: $631,225

Case study Risk Management Comments Unclear accountability and communication channels Nursing concerns were not heeded Role of pharmacist is unclear Defendant did not document her actions Defendant did not physically assess the resident despite evidence of acute G.I. bleed Oversight of the resident was not maintained by any individual practitioner

Case study Risk Management Recommendations Clearly define role of scope of practice of APN All communication is to be documented in a pre-defined, consistent, confidential manner Each resident must have an identified attending physician On-call practitioners must physically asses deteriorating resident when physician unavailable Do not fax information without providing original documentation in the resident’s health record

Review

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

Review Document the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) Contemporaneously record patient care. Record the time you gave a medication, the dose, administration route, and the patient's response. Record precautions or preventive measures used. Record each telephone call to any member of the patient’s treatment team, including the exact time, message, and response. Document a patient’s refusal to allow a treatment or take a medication Late entries should be noted as such, and should include the date and time of the late entry.

Review Don't use shorthand or abbreviations unless they are included in the approved abbreviation list. Don't write imprecise descriptions. Don't use excuses, opinions, or subjective statements. Do not copy and paste without proper attribution. Don’t 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 HIPAA and Patient Privacy Practicing Competent Nursing 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 Practicing Competent Nursing Understand your state’s Nurse Practice Act Comply with policies, procedures and regulatory requirements Seek additional educational opportunities 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 Quality Monitoring Participate in investigations Maintain confidentiality of all information

Questions?

Disclaimer 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, Aon, 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. 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. 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.