The MOST IMPORTANT ROLE of the MEDICAL RECORD is to assure that the high-quality patient care you provide is documented in a _____ and _____.
clear and concise manner
One of the CARDINAL PRINCIPLES of legally defensible documentation is
- Adherence to organizational POLICY and PROCEDURES (P&P).
- Standards of care, guidelines, competencies, and any other organizational document that guides the care of patients.
In any medical liability claim the _____ are UPHELD as the STANDARD AGAINST which YOUR ACTIONS ARE JUDGED.
organizational care provision documents
two of the three MOST FREQUENT ALLEGATIONS AGAINST NURSES in medical liability claims deal with documentation
- Absence of documentation regarding treatment.
- Timing of documentation (late entries).
- Chain of Command implementation.
Chain of Command = the proper reporting pathway nurses follow to ensure concerns are heard, decisions are made, and patient care is never compromised.
_____ is the FIRST THING SCRUTINIZED in medical liability claims dealing with nurses.
Documentation
Documentation that is _____ and _____ is the nurse’s BEST DEFENSE AGAINST LITIGATION.
complete and timely
_____ Includes ALL FORMS OF A DOCUMENTATION by a doctor, nurse, or allied health professional (physiotherapist, occupational therapist, dietician, etc.) recorded in a professional capacity in relation to the provision of patient care.
Fundamental part of clinical practice:
1. Demonstrates CLINICIAN’S ACCOUNTABILITY
2. RECORDS their professional practice
DOCUMENTATION
Appropriate Documentation Promotes:
- A high standard of clinical care
- Continuity of care
- Improved communication and dissemination of information between/across service providers
- An accurate account of treatment, intervention, and care planning
- Improved goal setting and evaluation of care outcomes
- Improved early detection of problems and changes in health status
- Evidence of patient care
Characteristic of a Medical Record and Clinical Documentation
CLEAR
CONCISE
COMPLETE
CONTEMPORARY
CONSECUTIVE
CORRECT
COMPREHENSIVE
COLLABORATIVE
PATIENT-CENTERED
CONFIDENTIAL
_____ Includes any and all forms of documentation BY A CLINICIAN recorded in a PROFESSIONAL CAPACITY in relation to the provision of patient care.
PROFESSIONAL DOCUMENTATION
WHO?
Must be recorded by DOCTORS, NURSES, MIDWIVES, PATIENTS, Other HEALTH PROFESSIONALS, or Other CARE PROVIDERS. Must be a record of FIRST HAND (direct) knowledge, observation, actions, decisions, and outcomes.
WHAT?
All aspects of patient care including: SUBJECTIVE and OBJECTIVES information, observation, assessment, actions, outcomes, variances from expected protocol, rationale for decisions, and critical incidents.
WHEN?
CHRONOLOGICAL RECORDS OF ACTIONS AND EVENTS, recorded at the time of or as soon as practicable AFTER THE ACTION OR EVENT, collaborations, variances, or critical incidents. Identified as a late entry if not timely.
WHY?
Purpose: BASIS OF COMMUNICATION, INFORMS AND RECORDS CARE, evaluates professional practice (quality improvement), demonstrates accountability, abstracts details for coding, and provides data for research/funding.
HOW?
Must be CONCISE, ACCURATE and TRUE RECORD; clear, legible, permanent, and identifiable; chronological, current, and confidential. Must avoid abbreviations, white space, and ambiguity.
Guidelines and Protocol in Documentation and Health Record
CPE
Comprehensive and complete record
Patient centered and Collaborative
Ensure and maintain confidentiality
Common Charting Errors
- Incomplete Documentation
- Vague/Subjective Terms
- Omissions (failing to do something that should have been done.)
- Illegible writing
- Late entries
- Copy-paste errors
- Pre-charting
- Unapproved abbreviation
7 Essential Components of Quality Nursing Documentation
- Centers on the patient
- Reflects the actual work of nurses.
- Reflects the objective clinical judgment of nurses.
- Proceeds in a logical and sequential manner, especially when evaluating a problem
- Is recorded concurrently with events
- Records variances in findings and in care. Does not duplicate information to be
found in other parts of the record. - Fulfills legal requirements.
Another way to look at documentation is to use _____ criteria to give you an OUTLINE to CRITIQUE and IMPROVE your DOCUMENTATION.
FACT
F
A
C
T
Factual
Accurate
Complete
Timely
F – Factual
Only information you see, hear, or otherwise collect through your senses
Describe, don’t label
Describe behavior, not conclusions (avoid words like confused, drunk, violent)
State facts, not value judgments (No change, Ate well)
Be specific
Use neutral language
Avoid bias
When you make an error:
State exactly what you did or failed to do
State that you notified the provider and their response
Do not state “by mistake” or explain how the error occurred
Report it on the incident report (or your facility’s error documentation form) and notify relevant staff
A – Accurate
Be precise
Quantify whenever possible
Make clear who gave the care
When countersigning with a student or another nurse:
Review the DOCUMENTATION CONTENT
Document your own follow-up assessment, INTERVENTIONS , and the patient’s RESPONSE
C – Complete
Include:
Condition change
Patient responses, especially unusual, undesired, or ineffective
Use of chain-of-command
Communication with patient and family
Entries in all spaces on relevant assessment forms
Use N/A or designation for items not applicable
DO NOT LEAVE BLANKS
T – Timely
In malpractice or negligence cases, DATE and TIME are critical to show a timely response
Do not leave documentation until the end of the shift → risk of forgetting key info
Chart as shift progresses for accuracy
Other professionals need up-to-date information to guide care
Computer entries are auto date/time stamped:
If referring to earlier events, note the time you’re referring to
NEVER document in advance
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Chapter 126
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Chapter 2: Lesson 1 (ETHICAL THEORIES, OTHER RELATED THEORIES AND VIRTUE ETHICS)18
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Chapter 2: Lesson 2 ( BASIC ETHICAL PRINCIPLES AND OTHER RELEVANT ETHICAL PRINCIPLES)16
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Chapter 2: Lessons 2.213
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Chapter 2: Lesson 313
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Chapter 417
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Chapter 518
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Chapter 6 (Lesson 1)15
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Chapter 6 (Lesson 2)6
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Chapter 6 (Lesson 3)3
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Chapter 728
