Documentation in nursing is critical to determine if the standard of care was rendered to a patient to defend nursing actions. Failure to chart, omissions and poor communication are hard to defend.
Crucial times are often those which nurses have the least time to document, such as periods involving abnormal vital signs, codes and transfers. Others include change of nursing shift reports and other patient hand offs. Take care when taking verbal orders, noting physician’s orders and verifying medication orders.
Critical values must be reported to the nurse within 15 minutes of lab verification. The nurse must report critical values to the physician within 30 minutes. If the physician can’t be reached, follow the facility’s fail safe plan.
“Dr. Smith called” could be interpreted as the nurse called and is awaiting a return call; the physician called the nurse, the nurse called and spoke to physician, etc. One suggestion is “MD paged, assessment findings discussed, and no additional orders at this time.”
Some facilities use nursing charts by exception indicating findings are “within defined limits” (WDL) unless otherwise noted. Know these defined limits. Charting by exception requires selecting “abnormal” and writing applicable text. In such cases, text will be carefully scrutinized.
Regardless of the charting method used, nursing documentation must be objective, legible, free of grammatical/spelling errors, free of errors/erasures, completed in blue or black ink, and accurate. Late entries and any corrections entered should be per policy and procedure. Allergies should be highlighted and flow sheets filled out completely. No charting should be done in advance.
Charting patterns including flow sheets will be reviewed. “Too perfect” charting may raise doubts. Patient assessment such as fall risk or skin assessments must be carefully performed and documented. Failing to do so is a common error.
An initial fall risk assessment incorrectly completed yielded a low risk score of 2. The correctly filled out score was 18, well above the facility’s high risk score of 6 or more. Failure to properly assess and identify the high risk patient and implement fall precautions contributed to two falls and injury. A complete and accurate skin assessment of a patient with a decubitus requiring surgery documented the decubitus was progressing at home rather than in the hospital, preventing a case against the hospital.
Careful nursing assessment makes spotting changes in the patient’s condition easier. Documentation should include staff notified and steps taken. One recommendation is the DARE approach: document Data, Action, Response, and Evaluation. The RN is responsible for analyzing data.
Consult the nursing policy and procedure for accepted abbreviations. Sign each entry correctly, including date and time. An illegible signature may lead to all nurses on duty being named in order to “cast a wide net.” Date and time are crucial when creating a chronology of events.
Document the position of the patient. Physical therapy charted, “Patient supine” many times in a chart of a patient who died after aspirating tube feeding. Did supine mean “on back” or “flat”?
Another patient was sent to the med/surg floor rather than to the ICU post operatively from a lobectomy. The patient coded the night of surgery. The physician wrote “Patient found on floor” Did the patient fall or did physician mean on med/surg floor?
Take caution with frequent flyers. It is easy to spot staff’s judgment. The nurse applied oxygen on one patient complaining of an impending sense of doom and documented, “Patient recovered from her previous little episode” which was the last entry before the patient died.
Evaluate any new onset of pain. One patient suddenly complained of a new onset of debilitating headache after he fell and hit his head in the hospital. This is documented as a “migraine” although there is no previous history of migraines. Then, 12 hours later, CT revealed brain stem herniation.
Hospital bills will be audited for items such as tubing charges, etc. to determine if policy and procedure was followed to prevent infections.
Privacy issues include retaining back - up records for prescribed time and avoiding fax and e-mail when possible. Always use a disclaimer.
The statute of limitation is typically 2 years and medical malpractice cases may be filed up to the end of the 2 years. It may take several more years before a potential case goes to trial. A nurse maybe testifying long after the events. Hence, to avoid all these troubles, it is important that you pay attention to nursing documentation. It may not just save your patients' lives but could be yours, too.