DOCUMENTATION

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DOCUMENTATION

• As a Loss Prevention Technique

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Todays Objective

• 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.

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Legal Perspective on Documentation

• Not documented, not done.
• Poorly documented, poorly done.
• Incorrectly documented, fraudulent.

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Quality Documentation is Quality Care

• Structured writing typically inspires structured
  performance.
• Document the Nursing Process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

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You are what you document

• A well-documented patient care record
• Protects your patient
• Demonstrates to the board of nursing that you are
  a competent nurse.
• Minimizes the potential of being named as a
  defendant in a lawsuit.
• Minimizes the potential of a court appearance if
  you ARE named in a suit.
• Help you win if you go to court.

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The Patient Care Record is a Legal Document.

• Under state laws, the patient care record is the
  property of the health care provider.
• Patient is entitled to a copy of the record under
  the laws of most states.
• The record must reflect accurate and
  contemporaneous information.
• The patient care record documents the care
  provided.

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Basis for Reimbursement

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

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Considerations for Quality Documentation

• Contemporaneous documentation
• Accurate documentation
• Fraudulent documentation
• Inappropriate documentation

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Documentation as a Loss Prevention Technique

• Documentation Dos and Donts
• 10 Risk Management Strategies

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Risk Management Strategy 1

• Do not erase.
• Do not use white out.
• Do not cross out an error with more than one line.

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Risk Management Strategy 2

• Record only the facts.
• Document only observed behavior.
• Document healthcare services rendered.

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Risk Management Strategy 3

• Do not write critical comments.
• Do not document your opinions.

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Risk Management Strategy 4

• Begin each entry with the date and time and end
  each entry with signature and title.
• Example
• (03/31/09 - 750AM - Jane Doe, BCCNS)

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Risk Management Strategy 5

• Do not leave blank spaces.

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Risk Management Strategy 6

• Record all entries legibly and in ink.

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Risk Management Strategy 7

• Avoid generalized phrases such as "bed soaked" or
  "a large amount."

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Risk Management Strategy 8

• If an order is questioned, document that
  clarification was sought and discussed.

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Risk Management Strategy 9

• Document only your own observations and patient
  services rendered.

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Risk Management Strategy 10

• Do not permit any visiting relative or other
  third-party access to the patient care record.

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Communication Challenges

• Attributes
• Factual
• Accurate
• Current
• Confidential

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Reporting Challenges
Nurses must communicate information about
patients to other nurses and other health care
workers.

• Oral Report
• Typically, conducted at change of shift.
• Documentation/Written Report
• Completed during shift.

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Documentation Techniques Strengths and Weaknesses
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Documentation Methods

• Charting by Exception
• FOCUS
• Narrative
• SOAP
• Electronic

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Documentation Methods

• Charting by Exception

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Documentation Methods

• FOCUS

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Documentation Methods

• Narrative

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Documentation Methods

• SOAP

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Documentation Methods

• SOAP (SOOOAAP)

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Documentation Methods

• Electronic

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Effective Risk Management Strategies

• Comply with Nurse Practice Act
• Practice Competent Nursing
• Comply with Policies and Procedures
• Follow Appropriate Incident Reporting

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Incident Reporting

• Losses can be reduced by a timely, prudent, and
  compassionate response to an incident!

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Learn Your Organizations Guidelines
Examples of Reportable Incidents

• Patient falls
• Medication errors
• Equipment failure
• Complaint by patient, family, visitor

• Treatment-related injuries
• Missed/incorrect diagnosis
• Employee exposures

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BE ALERT! Report unusual occurrences

• Document ONLY the facts

• Report immediately, i.e., within 24 hours.
• Do not speculate.
• Do not draw conclusions.
• Do not document impressions.

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QUALITY MONITORING

• Participate in investigations.
• Maintain confidentiality of all information.

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Open Charting

• Encourages patients to review their own patient
  care record
• Promotes meticulous documentation by healthcare
  providers
• Fosters patient inclusion in the healthcare
  delivery process
• Requires significant time
• May raise patient queries regarding the
  healthcare delivered

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Documentation Examples
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Documentation Bloopers

• Patient had waffles for breakfast and anorexia
  for lunch.
• She is numb from her toes down.
• While in ER, she was examined, x-rated, and sent
  home.
• The skin was moist and dry.
• Patient was alert and unresponsive.
• Rectal examination revealed a normal size
  thyroid.
• She stated that she had been constipated for
  most of her life, until she got a divorce.
• Skin somewhat pale but present.
• Patient has two teenage children, but no other
  abnormalities.

• The patient refused an autopsy.
• The patient has no previous history of
  suicides.
• Patient has left white blood cells at another
  hospital.
• On the second day, the knee was better, and on
  the third day it disappeared.
• The patient has been depressed since she began
  seeing me in 1993.
• Discharge status Alive but without permission.
• Healthy appearing decrepit 69-year old male,
  mentally alert but forgetful.

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THE END