Legal Documentation - 1 Nursing CE

Course Objectives:

Introduction – In today’s healthcare arena the nurse not only has a professional responsibility, but is also held accountable to document patient data that accurately reflects nursing assessment, plan, intervention and evaluation of the patient’s condition. In addition to this professional responsibility, nursing documentation is also significant for the following reasons:

Legal Protection – Nursing documentation is often the starting point in many malpractice cases. Accurate nursing documentation can either deter a plaintiff from filing a lawsuit or provide the leverage that is required to initiate one. In reviewing nursing documentation it is critical to show that the set standard of care was met. (Nursing organizations, regulatory agencies such as JCAHO and hospital policy and procedure set these standards). Jurors and attorneys view what is written in the patient’s record as the best evidence of what really occurred. For these reasons it is extremely important that nursing documentation is timely, accurate and complete.

Regulatory Standards – Joint Commission is probably the most notable regulatory agency and in recent years has embraced the concept of performance improvement that emphasizes the importance of outcomes and a multidisciplinary approach to the delivery of patient care. For purpose of Medicare and Medical funding, a healthcare facility must comply with the documentation regulations that are issued. Other Federal regulations such as those issues by the U.S. Department of Health and Human Services must also be followed to assure that Medicare recipients are receiving the proper care.

Reimbursement – With the evolution of managed care, the nurse’s role in cost containment and charge capture has taken a strong focus. Third party payers are now not only concerned with what care was given, but also with how it was delivered. Clinical records are now scrutinized by such third party payers as Medicare, Blue Cross/Blue Shield, etc. to be sure that the billed service was not only delivered, but that it was actually required in the first place. Without accurate and compete nursing documentation that clearly describes service and treatment, healthcare facilities stand to lose substantial revenue through denied reimbursement.

Societal factors that affect nursing documentation include:

Increased Consumer Awareness – The media, popular magazines and healthcare based organizations are putting forth great energy to assure that the healthcare population is aware and informed about nursing issues and treatment options. The healthcare consumer is now demanding high quality care that can be given at a reasonable cost. Consumers now expect nurses to be knowledgeable, competent and at some levels flawless in their delivery of care. Because of this newfound public knowledge, it is absolutely necessary that evidence of this high quality care be reflected in all nursing documentation.

Increased Acuity of Hospitalized Patients – Because of changes and reimbursement in payer mix (third party insurers), the outpatient setting has seen a large growth of consumers, which has increased the acuity of the in-patient immensely. Also increasing the acuity in the in-patient setting is the elderly population that is being cared for. This patient population presents with more complex and chronic issues. With the elderly population, additional nursing documentation is usually required, and this needs to include plans for the patient after discharge.

Increased Emphasis on Outcomes – Prospective payment systems, medical malpractice lawsuits and limited healthcare resources has made the quality of healthcare a major issue. Cost containment (avoiding unnecessary expenditure), renewed sense of competition (comparing outcomes with quality and price), and recognition of geographically variant standards (different regions provide different services). It is documentation that is the main mechanism of gathering this data. If you have heard of a new charting trend called “outcome charting”, it is this type of information that organizations are trying to capture.

Documentation should include the following (Charting Tips):

• Direct quotations from the patient, family or visitors
• Data that has been gathered
• Actions taken
• Individuals notified about concerns and issues
• Evaluation of Actions

Legal Aspects of charting should include:

• First, making sure you have the correct chart (MOST IMPORTANT PRIORITY)
• Writing neatly and legibly (with blue or black ink)
• Conveying significant details
• Signing and dating every entry
• Using proper spelling, grammar and appropriate medical phrases
• Using authorized abbreviations only
• Assuring patient’s name is on every page
• A single line through entry errors and your initials (no erasing or “white out”)

Nursing documentation and progress notes that are filled with misspelled words and poor grammar create a negative impression. Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless.

The following are true examples of spelling errors noted on nursing flow sheets:

• MD order: Walk patient in hell.
• Patient lying on eggshell mattress.
• Fecal heart tones heard.
• Patient observed to be seeping quietly.
• Foley draining fowl smelling urine.

The following are true examples of errors in grammar and incorrect use of words noted on nursing flow sheets:

• MD order: “May shower with nurse”
• “Patient has no rigor or chills, but husband states she was hot in bed last night”
• “Large BM up walking in the hall”
• “Patient had a cabbage done”
• “The pelvic exam was done on the floor”
• “Vaginal packing out, Doctor in”
• “Skin – Somewhat pale but present”

In addition to taking care to use appropriate grammar and use of words, it is also important to avoid writing inappropriate comments on the nursing flow sheet. Finger pointing and accusations of incompetence are surely a “red flag” to lawyers and jurors. Evidence of fighting among healthcare professionals in the nursing documentation is just what a plaintiff’s lawyer is looking for. The following are true examples of inappropriate comments found in nursing and physician documentation:

• “IV infiltrated because nightshift forgot to check it”
• “Patient going into shock, could not reach Dr. Jones per usual”
• Physician Note “Once again, the lab forgot to draw the patient’s PTT this am”
• Physician Note “If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here”
• “Patient received insufficient care today because nurse patient ratio was 1:7”
• “Physician Note: “Patient fell due to lax nursing supervision”
• “Patient in extreme pain because previous nurse too busy to give pain meds”

The “Risk” of abbreviating in legal documentation:

When documenting, it’s imperative that you don’t put your patient’s life at risk because of the abbreviations that you use. Abbreviations can be extremely dangerous to you and your patient, besides being a major waste of time.

The following are reasons why you should avoid abbreviations:

Abbreviations can be a total mystery to the reader. If a physician wrote, “Patient may get up AFAWG,” would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still wouldn’t have the correct answer. (For the record, this was a physician order and AFAWG means “As far as wire goes”).

Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use “u” for units. Another critical error can occur with the use of “ug,” for “microgram,” which has been misinterpreted to mean “mg,” for “milligrams.” Errors such as these occur more frequently then we would like to admit, and all because someone used and unclear abbreviation.

The less space you have for documentation, the more inclined you may be to abbreviate. Make sure that there is adequate space on your flow sheet for your documentation. The tendency is to force a lot of information into small spaces, thereby avoiding having to document in the progress notes. The results are often creative or imaginative but useless, wasteful, and uncommunicative.

JCAHO Standard for Approved Abbreviations:

It has been reported that as much as 15% of the medication error reports received by the NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) have occurred because of illegible handwriting, problems with leading and trailing zeros, misinterpreted abbreviations, and incomplete medication orders. To "improve the effectiveness of communication among caregivers," JCAHO is requiring facilities to develop their own list of abbreviations, acronyms, and symbols that should not be used. In addition to facilities individual choices, JCAHO has published a list of unapproved abbreviations that must also be adopted. The following chart includes the JCAHO unapproved abbreviations list which gives suggestions, mandates and expansion options:

Unapproved Abbreviation	Intended Meaning	Misinterpretation	Correction
> and <	Greater than and Less than	Mistakenly used opposite of intended	Write out “greater than” and “less than”
Ug (**)	microgram	Mistaken for “mg” milligram	Spell out “microgram”
Any drug name abbreviations	HCI, AZT, DPT, HCTZ, MTX	Can be misinterpreted for another medication	Spell out the intended medication
Cc (**)	Cubic centimeter = mL	Misread at “U” units	Write “mL”
IU (*)	International Unit	Mistaken for IV or the number 10	Write “International Unit”
MS, MS04, MgS04 (*)	Morphine Sulfate or Magnesium Sulfate	The two are mistaken for each other	Write “Morphine Sulfate” or “Magnesium Sulfate”
q.d, QD, QOD (*)	Every day or Every other day	The two are mistaken for each other	Write “Daily” or “Every other day”
ss	Sliding Scale	Mistaken for the number 55	Write “sliding scale”
Subq or SC (**)	Subcutaneous	Mistaken for “SL” (Sublingual)	Write “subcutaneous”
T.I.W. or t.i.w.	Three times a week	Mistaken for three times a day	Write “three times a week” suggest writing actual days
U or u (*)	Unit	Mistaken for a zero or a 4 ex. 4U seen as “40”	Write “Units”
Zero after decimal point (1.0mg) (*)	1 mg	Mistaken for “10mg” if decimal is not seen	Do not use terminal zeros after whole numbers
Zero not placed in front of decimal (.5mg) (*)	.5mg = 0.5mg	Mistaken for “5mg” if decimal is not seen	Always use zero before a decimal when the dose is less then a whole unit

(*) Is a JCAHO minimal requirement “Do Not Use” abbreviation list

(**) Is an expansion option of the JCAHO “Do Not Use” abbreviation list

No (*) is a suggested “Do Not Use” abbreviation

References

Wolters-Kluwer (2008). Complete guide to documentation (2nd ed.). Lippincott, Williams and Wilkins. Ambler, PA

Awareness Productions. (2004). Nursing documentation must make sense, must have meaning and must communicate. Retrieved on October 28, 2004 at: www.awarenessproductions.com/

Balton, Robert, R., Ph., Department of Pharmacy, Baylor University Medical Center. Abbreviations: Short cuts to failure. Retrieved on December 5, 2004 at: http://www.txhima.org/

Iyers, Patricia, W., & Camp, Nancy, H., (1999). Nursing Documentation: A Nursing Process Approach. (3^rd ed.). Mosby St. Louis

Joint Commission of Accreditation of Hospital Organizations. (2004). Unapproved Abbreviations. Retrieved on December 5, 2004 at: www.jcaho.org

Nursing Documentation. (2004). Medical record purposes and confidentiality. Retrieved on December 5, 2004 at: www.medtrng.com/

Scott, Susan, RN., (2003). Your license may depend on proper documentation. Retrieved on December 5, 2004 at: www.medicalcareersource.com/