The requirements for documenting patient care are constantly changing with the rapid evolution of technology in the healthcare environment.
The accountability of nurses has also shifted to a higher level. Allegations are brought against nurses more frequently now than ever before because nurses used to be thought of as custodians of patients and now are thought of as trained, skilled and knowledgeable clinicians.1
For example, a nurse as custodian may emanate: “A patient develops skin breakdown because of the nurse’s failure to reposition the patient according to the turning schedule.” A nurse as clinician may emanate: “A lawsuit alleges the nurse with failure to identify the patient’s risk for skin breakdown and initiate appropriate preventative measures.”
The extended risk exposure for the nurse as a clinician includes the areas of:
- communicating change in condition;
- applying appropriate nursing diagnoses;
- interpreting diagnostic findings;
- modifying the plan of care; and
- medication administration.
Justification for Documentation
The purpose of the medical record is to preserve a complete and accurate recording of all relevant care provided to a patient as a legal document.
The entries healthcare providers make in a medical record should tell the chronological story of how patient care events unfold. How the story is told can and does make a difference when patient care is reviewed.
Apply the FACT rule to all medical record entries:
- Factual entries mean objective entries. In other words, document your senses: what you hear, see, feel, and smell. Only first-hand knowledge should be recorded.
- Accurate entries include details of the events including dates and times, quotations of comments made by patients or other individuals present at the time, and discussions with healthcare providers who have the authority to give orders are a few examples.
- Concise entries represent the activity, issue or discussions without lengthy narratives.
- Timely entries include the date and time for all entries when recording as close to the timing of the events as possible. The electronic medical record time stamps all entries at the time the key strokes are made.
Documentation should reflect utilization of the nursing process to plan patient care and all nursing actions are within the nurse’s scope of professional practice. The National Council for State Boards of Nursing website provides a link to access the scope of practice for each state board.2
If nursing actions exceed the boundaries of the professional scope of practice, allegations can be brought against nurses for practicing medicine without a license.
Standards of Care (& Privacy)
Privacy and confidentiality must be maintained at all times and in accordance with the Privacy Rule,3 Health Insurance Portability and Accountability Act (HIPAA)4 and Health Information Technology for Economic and Clinical Health (HITECH).5
Organizations are required to draft and approve policies and procedures that define access, use and disclosure of a patient’s personal health information. Nurses have been terminated from employment for breaching privacy and confidentiality of patients.6
Particular situations are managed in an organization by policies, procedures and protocols. These documents outline and define how healthcare providers manage specific patient care situations which establish a standard of care as defined by an organization.
A standard of care should be consistent with current acceptable practice in the field of nursing and medicine. Nurses failing to follow policies and procedures are vulnerable to allegations of a breach in the standard of care.7
All nurses must be familiar with documents approved by the organization where employed and adhere to them. If policies and procedures do not represent accepted practice standards, action should be taken to correct the content through appropriate channels within the organization.
Regulatory agencies, such as the Joint Commission (TJC),8 Det Norske Veritas Healthcare (DNV)9 and the Centers of Medicare and Medicaid Services (CMS)10 establish minimum expectations for quality patient care in healthcare facilities.
The Code of Federal Regulations (CFR)11 defines the minimum expectations for quality patient care. Standards written by TJC and DNV are published in accreditation manuals.
Documentation in a medical record validates the quality of patient care. The National Patient Safety Goals12 published each year by TJC set new standards healthcare facilities must meet. Communication among healthcare providers must improve to increase patient safety.
A few practices in place designed to improve communication are: time out before procedures, verbal and telephone order read-back, and critical value reporting.
Communication exchange between healthcare providers is enhanced by using hand-off and SBAR techniques.
Nurses should be familiar with the regulatory requirements applicable to their clinical area and entries in the medical record should reflect adherence to regulatory agency requirements.
Healthcare professionals are faced with more challenges regarding documentation because of our litigious society and because of the incorporation of electronic medical records (EMR) in clinical practice settings.
When the EMR fields do not capture what is necessary to tell your story about the patient care you provided, you must add the necessary information through free-text entry fields or annotated nurse’s note to assure you can defend your care several years from now.
Implementing documentation strategies will decrease your exposure to litigation and enhance patient care. See recommendations in the Table regarding strategies proven to reduce your liability exposure.
References for this article can be accessed here.
Rachel Cartwright-Vanzant speaks to organizations and presents public seminars nationally on legal, ethical and healthcare related topics. She is president/CEO of Medical Legal Concepts LLC., a consulting firm for medical and legal professions, and founder of Nursing Impact, an online education and support community for nurses, both in Palm Beach Gardens, Fla.