3 ObjectivesDiscuss current issues with electronic health record documentationDiscuss documentation strategies to best utilize electronic technologyIllustrate documentation concepts in case studies
4 Documentation No documentation Poor documentation Confusing documentationConflicting documentationMissing documentation
5 Documentation LEGAL ISSUE Inadequately documented medical record can be your worst liability!A well-documented medical record can be your greatest legal asset!LEGAL ISSUE
6 Documentation Essentials Assessment – What did you see or not see?FrequencyInterventions – What did you do? Who did you tell?Response to interventionsPlan of care
7 Documentation Data from external sources flow into EMR EFMVital signsHemodynamicsValidation of dataIs the information accurate?
8 Documentation Myth“If it wasn’t documented……it wasn’t done”
9 Documentation – Example What are the components of documentation that need to be included in regards to the EFM strip?
10 Documentation Example “Doctor aware. No orders received”
11 Documentation - Example Prolonged deceleration noted at 2217, lasting x 5 minutes. BP 122/74, Uterine activity WNL, Maternal position change left side, right side, knee chest, O2 started at 10L fm, 500 mL IVF bolus, Cervical exam = C, + 3 station (rapid change), No cord felt, physician notified at 2219 – coming to room, Charge RN notified and requested additional assistance. Preparing patient for vacuum assisted delivery. NICU notified for presence at birth. Plan to assess FHR q 5 minutes. OR team and anesthesia notified – on standby.
12 Case Study – Communication & Documentation RN assigned to patient from 7am until time of birth at 12:58pmPhysician examines patient at 8:35 am, leaves hospital for officePatient begins to show slow or no progress; oxytocin increased with resulting tachysystole and prolonged deceleration; fetal tachycardia and minimal-absent variability followed the decelerationAt 10:25 am RN reports to physician that the patient is complete, pushing effectively with no mention of oxytocin dose, abnormal FHR parameters. Neither RN or physician remembers who initiated phone call.
13 Case StudyAt some point, the Charge RN becomes involved in patient care, but no documentation is made as to whom, if anybody, contacted her or if she just happened to be there.Patient allowed to “labor down” and oxytocin is stopped around 11:00 am with the RN contacting the physician.Charge RN did not contact physicianPhysician arrives at 12:30 pm expecting to see normal EFM strip
14 Case Study – Physician Deposition Q: And it’s the nurse’s job to tell you when you should come to the bedside?A: It’s the nurse’s job to inform you of what the status of the patient is, the fetus and the mother, in which you decide if you want to come to the bedside.Q: Did you rely on Nurse ______ to perform that function?A: Yes
15 Case Study RN documentation did not reflect correct EFM assessment In the 8 hours that the patient was in labor, the physician only checked on the patient 2 timesThe child has cerebral palsy. Plaintiffs were able to use the poor communication and miscommunication regarding the strip to force a substantial settlement.This case was made on the finger pointing by one physician. Had the RNs and physician documented their actions and their plan of care, the damages may have been substantially mitigated.
20 Documentation - Safe Quality Measures “We measure what we value and we improve what we measure”AWHONN
21 AWHONN Measure 02: Second Stage of Labor Mother-Initiated, Spontaneous Pushing Mother-initiated, spontaneous pushing in the 2nd stage of labor begins at the time the patient feels the urge to push. Spontaneous pushing is defined as a mother’s response to a natural urge to push or bearing down effort that comes and goes several times during each contraction. It does not involve timed breath holding or counting to 10.Documentation in the medical record will reflect nursing education to the patient regarding the 2nd stage of labor; patient’s report of feeling pressure or the urge to push prior to initiation of active pushing and evidence of nursing support during the 2nd stage of labor.Mother-initiated pushingAssisting the patient into upright, gravity-neutral positionsEncouraging grunting or vocalization during the push in response to contractions.
22 Documentation - Safe Order Entry Clear Concise Match policy/care guidelines
23 Documentation - Effective Trending of DataVital SignsLabsIntake and Output
24 Documentation - Effective Ability to recreate clinical pictureFragmented documentationIf you were unaware of previous patient care data, would you be able to look at medical record and determine care needs?
25 Documentation - Effective Essential categories of assessmentLegal Issue: Assessment parameters are incomplete or not available for documentation
26 Documentation - Effective Will you remember the specifics about your care several years later?InterventionsSequence of events and interventionsCommunicationTiming
28 Assessment parameters Non-invasive assessment of hemodynamics and tissue perfusionPulsesQuality of pulsesSkin colorSkin temperatureCapillary refillMucous membranesHeart soundsBreath soundsUrine – amount and color
29 Abnormal Assessment Parameters Are normal parameters defined?What should the RN do when assessment parameters fall outside of normal values?How are abnormal parameters documented?Example: Maternal HR 122, documentation WNL
33 “Department of Redundancy Department” Staffing GuidelinesFrequency of documentation requirementsPhysician/RN/Anesthesia_____________________________________________Bottom LineWe don’t have timefor this!
34 Plan of Care documentation What was the Physician/CNM/RN thinking?Weakness in most systemsLiabilityExample: Fetal heart rate with abnormal assessment parameters, but remains in Category II with some reassuring findingsWhy did you continue to watch abnormal parameters?Plan of Care is not a form!
35 Narrative Discreet data Are there limitations to the amount of narrative documentation?Ability to expandclinical assessmentAbnormal assessment parametersplan of careCommunication with other healthcare providersWhat was the specific communication?Is there ability to document communication?
36 Documentation - Equitable Prenatal RecordsAbility for off service Physicians/RNs to document consultation in EMROperative suitesAntepartumOutpatient OB ClinicIntensive CareEmergency DepartmentMedical – Surgical UnitMain OR
37 Medication Reconciliation OutpatientInpatientTriageAdmissionChange in service/unitDischarge
45 Case StudyRN Documentation: “Pt. pushing. Friends holding and supporting legs. Comfortable with epidural”Physician Documentation: “Pt. did not have particularly good pushing effort, nor particularly good control, and was fairly emotional and uncooperative”
56 Case Study – Second Stage Summary Vacuum extractionFundal pressureNucal cord – tight – reducedMcRoberts maneuver performedSuprapubic pressureCould not reach posterior arm4th degree episiotomyDelivered posterior arm
57 Case Study – Delivery @ 2121 Pediatrics in attendance Apgars 1 (1) and 2 (5)Physician Note: “a segment of cord was obtained for a gas, but somehow the nursing staff did not draw the gas and it clotted”EBL = 1200 cc
58 Case Study – RN Documentation “Pt. tired, pushes well at times. Baby coming down with vacuum”No documentationFetal station# vacuum attemptsHow long vacuum appliedPatient cooperationFundal pressureShoulder dystociaManeuvers to correct
59 Case Study – RN No interventions Anticipation Oxygen not started Pitocin remained at 22 mu
60 Case Study – Physician Documentation “Vacuum applied and vertex pulling to crowning position over 5-6 UCs over about a 30 minute time period. At that time, pt. became very combative and uncooperative. The pt as I said was very uncooperative and did not push with any effort. With fundal pressure and continued pushing, male infant delivered”
61 Case Study – Newborn Outcome Birth asphyxia diagnosedDevelopmental delay
62 Case Study – Legal Outcome Depositions: “During vacuum, physician placed leg on the foot of the bed and pulled until red in the face and shaking; leaned back on stool; feel off stool; delivery table fell over”RN experts x 2 – unable to defendLegal case settled