1. Documentation
For Nursing Professionals

2. 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

3. Importance of Documentation
Legal
Reimbursement
Research
Communication and Quality Improvement 3

4. What is Malpractice?
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.
Malpractice is a type of negligence that pertains to professionals.
Nurses and other professionals can be sued for malpractice.
(ADVANCE SLIDE.) 4

5. What is Malpractice? Duty Breach Cause Harm
There are four elements that must exist for an incident to be considered malpractice: Duty of care, Breach of duty, harm, and causation.
As a licensed nurse, you have a responsibility to treat your patients according to the standards that are recognized by your profession as being acceptable treatment, that a reasonably prudent nurse under like or similar circumstances would provide, or the standard of care.
Then, a breach of that standard of care has to be established, such as failing to notify the practitioner of a change in the patient’s condition, an equipment use error, or administering the wrong dose of a medication. Patients have the right to expect healthcare professionals to provide care that meets the standard of care for their profession. Therefore, negligence can be established if it is determined that the standard was not met during the course of treatment.
However, in order for a claim of medical malpractice to be valid under the law, the patient must have sustained an injury that was directly caused by the practitioner’s negligence or error. Just because there was an unfavorable outcome does not necessarily mean that negligence or malpractice was the cause. There can be an injury without negligence and there can be negligence that does not result in injury.
Finally, the injury must have resulted in damages, or harm to the patient. These damages can be in the form of disability, loss of income, pain, suffering, medical bills, and more.
(ADVANCE SLIDE.) 5

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

7. Legal Perspective Not documented = not done
Poorly documented = poorly done
Incorrectly documented = potentially fraudulent
To recap from a legal perspective on documentation --
Not documented, not done - If the healthcare services rendered are not documented, it may be alleged that the services were not performed.
Poorly documented, poorly done - If the healthcare services rendered are insufficiently documented, it may be alleged that the services were performed in an inferior manner.
Incorrectly documented, fraudulent - If the health care services rendered are Incorrectly documented, allegations of fraud may arise.
(ADVANCE SLIDE.)

8. Reimbursement
Your documentation may influence how you and your employer are reimbursed for services rendered and can help minimize financial loss.
For billing purposes, documentation should include:
The actual provider
The service or services provided
The diagnosis
Good documentation is often used as the basis for how healthcare professionals are paid for services rendered and in minimizing financial loss.
We’re not going to go into too much detail on reimbursement (today), but keep in mind that for billing purposes, documentation should include (1) the actual provider, (2) the service or services provided and (3) the diagnosis. These facts should already be in the patient’s care record.
Failure to follow billing rules can result in payment denial, repayment of fees already paid, mandated educational activities, fines, fraud prosecution, loss of Medicare and/or Medicaid billing ability, and loss of employment.
(ADVANCE SLIDE.)

9. Research
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
The prevalence of electronic health records makes it easier than ever for researchers to mine available information for research purposes. Computerized searches of large troves of de-identified patient medical information can help lead to a better understanding of disease patterns, treatment efficacy, and the contribution of genetic and other factors in health.

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

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

12. Good Documentation: What to record
Facts
Observed Behavior
Services Rendered

13. 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

14. Good Documentation: Writing Style
Specific
Clear
Complete
Concise
Sequential
Timely
Avoid generalized phrases
Avoid error-prone abbreviations

15. Standardized Terminologies
Use only facility-approved abbreviations
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)

16. Special Notes: Electronic Health Records
Patients’ privacy must be protected
Ensure that key patient identifiers are accurate
Avoid copying and pasting when documenting high-risk items
Do not copy and paste another clinician’s notes without proper attribution
Do not delete original source text or data and insert it elsewhere in the record
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.

17. Patient Privacy/HIPAA
Check that you have the correct chart by double-checking patient identifiers before you enter any information.
Do not permit any visiting relative or other third-party access to the patient care record.
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

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

19. Remember:
Not Documented?
Not Done.

20. Documentation Techniques
Charting by exception
FOCUS
Narrative
SOAP
SOOOAAP

21. 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.

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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: (National Council of State Boards of Nursing)
Follow professional organizations and journals on social media for trends and updates to nursing practice

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

33. 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

34. Incident Reporting
It is important to know and comply with your institution’s incident reporting guidelines
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

35. 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 healthcare informational record does not take the place of an incident report, and vice versa
Use the patient’s healthcare informational record for clinical observations only
Do not mention the incident report in the patient’s healthcare informational record

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

37. Case Study

38. Case Study
A 23-year-old woman with no significant medical history presented to the emergency room with flu-like symptoms.
She complained of generalized body ache and had a fever of
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.
Her worsening symptoms motivated her to seek care a local emergency room.

39. Case Study 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
The emergency department physician admitted the patient to the intensive care unit under the care of an attending physician.
The patient was started on oxygen and antibiotic therapy.
Blood cultures were drawn and showed Streptococcus Pneumoniae and antibiotics were appropriately adjusted per recommendation of the infectious disease specialist.

40. Case Study
The attending physician first saw the patient in the intensive care unit.
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.
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).
The physician ordered 30mEq of potassium to be added to each bag of the patient’s intravenous fluid, infused at 80 milliliters per hour.
The order was to be maintained through the remainder of her course of treatment.

41. Case Study
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 mEq of potassium to be administered by mouth.
The patient vomited the medication (amount retained undetermined).
The attending physician then ordered two doses of 40 mEq of intravenous potassium to infuse over a four hour time period with the plan of increasing the potassium level between 4 and 4.5.
Documentation is problematic.
It appears that despite the order for two doses of potassium 40 mEq to be infused over four hours, the intensive care unit nurse administered two intravenous potassium doses of 20 mEq over approximately one hour (documentation regarding this is inconclusive).

42. Case Study
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.
The intensive care unit nurse did not specifically notify the physician of the pattern of rising heart rate.
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.
He ordered a pulmonary consult for possible bronchoscopy but deemed that she was stable, and that vasopressors and aggressive pulmonary treatment were not necessary.
He ordered the patient to be transferred to the telemetry unit.

43. Case Study
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.
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.
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.
Regardless of the actual reason, there are no telemetry unit electrocardiogram strips for this patient.

44. Case Study
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.
The on-call emergency physician attempted to resuscitate, but was unable to obtain a heart beat and the patient was pronounced dead.

45. Discussion 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?
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?
If yes, how much?

46. Case Study
The family of the deceased sued the attending physician, the hospital and three of the hospital’s registered nurses, and sought $3,000,000 in damages.
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

47. Case Study
Initially, the defense team felt the intensive care unit nurse had a strong case.
She stated she had done nothing wrong.
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.
She recalled administering the potassium and believed she had advised the physician when necessary.
She further believed she had properly documented her actions throughout her care to the patient.

48. Case Study
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.
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.
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.

49. Case Study - Outcome
The expert witness stated the intensive care unit nurse’s care and treatment of the patient was not medically defensible
The claim against the intensive care unit nurse settled at mediation for $100,000 with an additional $6,152 in legal expenses.
The total settlement amongst all of the defendants in the case was $1.4 million.

50. Case Study Risk Management Comments
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.
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.
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.

51. Case Study Risk Management Comments
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
There is no documentation to verify that the patient was transferred with a cardiac monitor and oxygen via nasal cannula as ordered.

52. 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:
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.
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.
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.
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.

53. Case Study Risk Management Recommendations
Monitor and document the patient’s vital signs, symptoms, response to treatment and changes in condition in the patient care record.
Timely report all significant findings to the patient’s physician.
Adhere to physician medication orders including the correct drug, dosage, route and administration times.
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.
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.
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.

54. Review

55. 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

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

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

58. 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

59. Questions?

60. 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.