Documentation Standards Presentation - ARNNL · Legal Rulings on Documentation ... Only if accurate...

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Documentation Documentation StandardsStandards

Lynn Power RN, BN, MNNursing Consultant - Practice

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DefinitionDefinition

… any written or electronically generated information about a client that describes the care or service provided to that client…

RNABC, 2002

Studies indicate approximately 2.5hrs/shift (27%) spent on charting

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Why DocumentWhy Document

Three main reasons:1st

Communicate client health information.Provide continuity of care.

2ndProvide Quality Assurance.Facilitate research.

3rdDemonstrate accountability.Legal Defense

CNPS 1996

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11stst Communication: Communication: Continuity of CareContinuity of Care

Wound CareHealing slowlyLarge amt of

drainageTenderSlightly reddenedEdges raw

Well Baby VisitHappyBonding wellFeeding wellGaining weight++ wet diapers

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TerminologyTerminology

What do these words mean?• Doing Well• Adequate amount• No complaints voiced• Teaching done• Appears largerUse proper names e.g. products!

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22ndnd Quality Assurance : Quality Assurance : ResearchResearch

• Agency Policies• CCHSA-

accreditation• QI-Audits• Public

accountability

• Registration forms• Communicable

diseases• Targeted activities

e.g. Care maps• Resource

management e.g. WLM, LOS

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Duty to Keep RecordsDuty to Keep Records

Legislation

ACTS –

Bylaws

Regulations

Examples – child abuse, consent, mental health, narcotic control,

Respecting Public Health & Operation of Hospitals in the Province of NL.

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33rdrd AccountabilityAccountability

Professional Responsibilities –Standards

Indicator 2.8: • Documents timely and accurate

reports of relevant observations, including conclusions drawn from time.

Identify your Designation

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AccountabilityAccountability

Demonstrates application of professional Standards :KnowledgeCompetent application- Nursing ProcessCode of ethicsPublic serviceProfessional & personal accountability

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Professional Conduct Professional Conduct ReviewReview

Unacceptable Documentation PracticesDishonesty – falsifying observations, orders,

treatments or nursing records either verbal or written.

Incompetence – Errors in practice Fraud – submitting false documents or lying

on license renewal forms

ARNNL, PCR 2002

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ARNNL Annual Report ARNNL Annual Report 20042004--20052005

Complaints against NursesAverage 5 per year (range 1-8 complaints)National Average 9/yr based on RN base Documentation Issues• Vague comments - subjective• Assumptions - no s/s or facts - labeling• Not timely – gaps –• No record of inter-professional

communication

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In a Legal Proceeding Documentation::Sets the Stage

Provides a chronological record of events- times and dates.Assist RN to recall details about care.

Sets your CaseAssist RN to persuade court that testimony is accurate, and care was reasonable and prudent.

33rdrd Legal DefenseLegal Defense

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Health record –retrospective account of events. Courts prefer oral testimony… More reliable, sworn oath, cross examined.Impressed with meticulous, clear, legible, & well organized records.


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Legal Rulings on Documentationnothing charted nothing done…

e.g. Kolesar v. Jefferies (post-op spinal fusion - no record from

2200-0600 hrs)

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Contemporaneous ChartingLink timing of note to accuracy and

credibility.

Third Party Chartingdestroys accuracy, diminishes

credibility

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Charting by Exception acceptable when:

• Procedure is consistently and uniformly applied

• Client baseline information is described at all significant intervals – trends, symptom changes

• Combined with flowsheets, pathways, protocols, current careplans etc to track normal

• Congruent with regulatory and accrediting bodies requirements.

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CNPS Annual Report 2005CNPS Annual Report 2005

Reported Lawsuits (%)

*2001-2005 CIHICommunity/Home Care 5.3 9.3ER/ Outpatients 9.3 8.5LTC 0.7 10.5L & D 21.2 5.3

* based upon % of calls

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Reported Occurrences (%)

* 2001-05 2005 CIHICommunity/Home Care 6.6 9.1 9.3L & D 14.1 14.6 5.3Medical/Surgical 11.2 14.5 17.7OR/ Recovery 13.5 12.7 4.0LTC 8.1 16.4 10.5

* based on % of calls

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Legal PitfallsLegal Pitfalls

Common Problems Include:• Failure to review previous charting• Failure to chart specific time care occurred

(within note)• Failure to record V/S , I & O• Failure to note – complaints, outcomes

www.mursingmanagement.com (2003)

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Reasons for Lawsuits Assessment/Dx 21.5% Communication 7.4% Treatment 30.2%Medications 8.1%Documentation 0 %

Occurrences Documentation 0.4-1.8%

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Quality of DocumentationQuality of Documentation

Remember your ABC’S

Follow established policies & rules for documentation

Chart Smart

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Rule #1Rule #1

Record immediately or as soon as possible.

Record actual time and time care occurred

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Rule #2Rule #2

Record only your own actions, and what you saw, heard, or did.

Don’t record staff problems.

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Rule #3Rule #3

Record in chronological order.

Don’t record in ‘blocks’ of time e.g. 0800-1200hrs

Don’t name another patient.

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Rule #4Rule #4

Record clearly, concisely, and in a factual manner. Don’t use words associated with errors eg unintentional, miscalculatedRecord your senses (hear, see, touch, smell)Use specific measurements – Industry standards eg wound measurement

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Rule #5Rule #5

Record frequentlyComplexity of patient’s condition – trends in statusDegree of risk involved in careAccepted standards, policies and proceduresMedical order

Increase Risk = Increase Chartinge.g. teaching, delegation, follow-up

CNPS

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Rule #6Rule #6

Correctionsdraw a straight line through text and initial.

Indicate mistaken entry NOT error Unsolved Mysteries –gaps in charting if an assessment is expected and not done OR pages missing

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Rule # 7

Late EntryCheck policy for definitionCheck with Management if >24hrsDate and label correctlyEnd of day charting risky – tired & in a hurry

OmissionOnly if accurate recollectionChart in next available space, cross reference to original

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Chart Smart TipsChart Smart Tips

All entries must be signed by the person who made the entry. Use your own passwordCountersigning/ Be cautious…what does it mean?

Can’t Delegate Charting.

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Write in ink. Do not change pens in the midst of an entry.

Don’t use highlighters.

Watch use of circles and squares e.g. meds

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• Don’t leave empty spaces- cross out with single line. ______________ Or if in a flowsheet write N/A

• When a note takes up 2 pages.. Sign the bottom of the 1st page and at the top of page 2 write “Continued Nov 13/03 @ 1100hrs”

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If abbreviations are acceptable, they should be uniform.System of reporting should be uniform throughout the whole system.

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ISMP Error Prone Abbreviations (2003)cc – mistaken “u” units- use mlD/C – mistaken discontinue-OD / od- once daily vs (r) eyeSC/ SQ – SLss – mistaken as 55

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Faxing SafeguardsFaxing Safeguards

• Call ahead and tell the recipient it is coming.

• Keep copies of fax receipts.• Write confidential on the cover sheet• If it goes to the wrong number call &

ask the recipient to destroy the material.

• Follow Check…Check…Recheck Rule

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Computer SafeguardsComputer Safeguards

• Take your time… look closely at what you are entering.

• Never tell anyone your password… or use anyone else's.

• Don’t leave client information displayed on the screen.

• Retrieve printouts immediatelyRemember computer files are permanent all

corrections are recorded.

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Telephone AdviceTelephone Advice

Is a Nurse-Client Relationship as such care given MUST be recorded.

Be consistent: Standard care plans, Log Books, tape recording

…. Audit each otherDon’t use “short hand”

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Incident ReportsIncident Reports

Describes incident, events, injury & corrective action.Does not ordinarily become part of the chart.An internal document for data and monitoring.Write as if suit could occur.

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Sharing InformationSharing Information

Juggling Act

Need to balance Privacy

-------------------Staff Safety

--------------------Client Care Needs

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A Good Offense is the A Good Offense is the Best Defense Best Defense

Documentation Standards Presentation - ARNNL · Legal Rulings on Documentation ... Only if accurate...

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