1. Documentation Issues with Electronic Medical Records
Suzanne McMurtry Baird, DNP, RN
Clinical Nurse Specialist
The Woodlands, Texas

3. Objectives
Discuss current issues with electronic health record documentation
Discuss documentation strategies to best utilize electronic technology
Illustrate documentation concepts in case studies

4. Documentation No documentation Poor documentation
Confusing documentation
Conflicting documentation
Missing 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?
Frequency
Interventions – What did you do? Who did you tell?
Response to interventions
Plan of care

7. Documentation Data from external sources flow into EMR
EFM
Vital signs
Hemodynamics
Validation of data
Is 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 12:58pm
Physician examines patient at 8:35 am, leaves hospital for office
Patient begins to show slow or no progress; oxytocin increased with resulting tachysystole and prolonged deceleration; fetal tachycardia and minimal-absent variability followed the deceleration
At 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 Study
At 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 physician
Physician 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 times
The 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.

16. EMR Wish List

17. Improving the Health Care System
Six Aims
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Crossing the Quality Chasm (2001) Institute of Medicine

18. Documentation - Safe
Checklists
Time out
Quality and safety
data

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 pushing
Assisting the patient into upright, gravity-neutral positions
Encouraging 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 Data
Vital Signs
Labs
Intake and Output

24. Documentation - Effective
Ability to recreate clinical picture
Fragmented documentation
If 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 assessment
Legal Issue: Assessment parameters are incomplete or not available for documentation

26. Documentation - Effective
Will you remember the specifics about your care several years later?
Interventions
Sequence of events and interventions
Communication
Timing

27. Assessment parameters
Uterine contractions
Fetal status
Frequency
Intensity
Duration
Resting tone
Baseline rate
Baseline variability
Periodic patterns
Accelerations
Decelerations

28. Assessment parameters
Non-invasive assessment of hemodynamics and tissue perfusion
Pulses
Quality of pulses
Skin color
Skin temperature
Capillary refill
Mucous membranes
Heart sounds
Breath sounds
Urine – 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

30. Documentation – Patient Centered

31. Documentation - Timely
Late notes
Time of late entry in comparison to patient care

32. Documentation - Efficient

33. “Department of Redundancy Department”
Staffing Guidelines
Frequency of documentation requirements
Physician/RN/Anesthesia
_____________________________________________
Bottom Line
We don’t have time
for this!

34. Plan of Care documentation
What was the Physician/CNM/RN thinking?
Weakness in most systems
Liability
Example: Fetal heart rate with abnormal assessment parameters, but remains in Category II with some reassuring findings
Why 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 expand
clinical assessment
Abnormal assessment parameters
plan of care
Communication with other healthcare providers
What was the specific communication?
Is there ability to document communication?

36. Documentation - Equitable
Prenatal Records
Ability for off service Physicians/RNs to document consultation in EMR
Operative suites
Antepartum
Outpatient OB Clinic
Intensive Care
Emergency Department
Medical – Surgical Unit
Main OR

37. Medication Reconciliation
Outpatient
Inpatient
Triage
Admission
Change in service/unit
Discharge

38. Ability To Document Emergency Situations
RRT
Code Blue
Operative vaginal birth
Shoulder dystocia
RN maneuvers
Provider maneuvers
Hemorrhage/MTP

39. Case Studies

40. Case Study – Patient History
G 1
EGA = 39 2/7 weeks
Elective induction – severe maternal discomfort
Cervix = 2 cm / 80%
0 station
Plan – oxytocin; epidural for pain management

41. Note:
39 week
Hard Stop

42. Checklist

43. Bishop’s Score Closed 0 – 30 -3 Firm Posterior 1 1 – 2 40 – 50 -2
Dilation
Effacement
Station
Consistency
Position of cervix
Closed
0 – 30 -3
Firm
Posterior 1
1 – 2
40 – 50 -2
Medium
Mid-position 2
3 – 4
60 – 70
-1,0
Soft
Anterior 3
> 5
> 80
+1, +2

45. Case Study
RN 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”

46. Oxytocin In-Use Checklist

47. Case Study - 2010 Cervix – complete Vertex LOA @ -1 to -2
Maternal temp 100.1
Fetal tachycardia
Plan – Vacuum extraction

56. Case Study – Second Stage Summary
Vacuum extraction
Fundal pressure
Nucal cord – tight – reduced
McRoberts maneuver performed
Suprapubic pressure
Could not reach posterior arm
4th degree episiotomy
Delivered 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 documentation
Fetal station
# vacuum attempts
How long vacuum applied
Patient cooperation
Fundal pressure
Shoulder dystocia
Maneuvers 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 diagnosed
Developmental 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 defend
Legal case settled