1. As a Loss Prevention Technique
DOCUMENTATION
As a Loss Prevention Technique
Note to the Educator:
The goal of this first module in the new Educator Toolkit is to deliver to educators a tool that they can easily utilize to supplement their instructions to nurses on the critical topics of Documentation and how it can serve as a loss prevention technique. Our hope is that this toolkit will deliver risk management information that supports and guides nurses to minimize their risk and promote patient safety. NSO works to achieve better risk management through several channels – such as Continuing Education materials and offerings, public speaking opportunities, NSO Risk Advisor newsletter publications, publishing articles on key topics to nurses, and now the new Educator’s Toolkit. Please utilize this toolkit (the presentations, handouts, worksheets, and quizzes) to help NSO spread good Risk Management tips to nurses.
Moving forward in the presentation, the information contained in the “notes” section of each PowerPoint slide is meant as supporting dialogue for you to use for your class.

2. Today’s 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.
One of the objectives of today’s presentation are to increase awareness of the documentation risks that are faced by nurses on a consistent basis. This presentation will specifically focus on legal exposures to claims of negligence and malpractice.
Another objectives is how to increase the quality of your own documentation by expanding awareness of ways to avoid malpractice incidents.
The third objective is to address what documentation steps you can take to help protect your patient from harm and yourself from a malpractice incident.
So, what is malpractice? Let’s define it.
(ADVANCE SLIDE.)

3. Legal Perspective on Documentation
Not documented, not done.
Poorly documented, poorly done.
Incorrectly documented, fraudulent.
To recap from a legal perspective on documentation --
Not documented, not done - If the healthcare services rendered are not documented, it may be alleged that the services were not performed.
Poorly documented, poorly done - If the healthcare services rendered are insufficiently documented, it may be alleged that the services were performed in an inferior manner.
Incorrectly documented, fraudulent - If the health care services rendered are Incorrectly documented, allegations of fraud may arise.
Now, let’s look at this from a quality perspective….
(ADVANCE SLIDE.)

4. Quality Documentation is Quality Care
Structured writing typically inspires structured performance.
Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
We need to always remember that quality documentation is quality care. Structured writing is a valuable practice to learn. It should be clear, to the point, and factual.
When you perform your documentation, there are 5 components of the Nursing Process to consider:
Assessment (of patient's needs)
Diagnosis (of human response needs that nurses can deal with)
Planning (of patient's care)
Implementation (of care)
Evaluation (of the success of the implemented care)
Now let’s review how good documentation can help you.
(ADVANCE SLIDE.)

5. 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.
Good record-keeping is a win-win action and can help in the following ways.
#1. It can protect your patient by increasing his/her quality of care.
#2. It can demonstrate to the Board of Nursing that you are a competent nurse.
#3. Good documentation can also keep you from being named in a lawsuit.
#4. And keep you out of court if you are named in a lawsuit.
#5. Lastly, in the event that you do go to court, keeping good records can help you win your case.
Let’s go over some legal reminders of documentation.
(ADVANCE SLIDE.)

6. 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.
A medical record or patient care record, as we’ll refer to it here, is a legal document that can be used to both help or harm the nurse in a legal setting.
A patient owns the information that has been documented and is entitled to a copy of the record.
Accurate & Contemporaneous recording of care contribute to its quality. Documentation is used to tell “the story” of the service provided.
Documentation can also have a financial impact on you. How can documentation have a financial impact?
(ADVANCE SLIDE.)

7. Basis for Reimbursement
Your documentation may influence how you and your employer are reimbursed for services rendered and minimize financial loss.
Good documentation is often used as the basis for how healthcare professionals are paid for services rendered and in minimizing financial loss.
We’re not going to go into too much detail on reimbursement (today), but keep in mind that for billing purposes, documentation should include (1) the actual provider, (2) the service or services provided and (3) the diagnosis. These facts should already be in the patient’s care record.
Failure to follow billing rules can result in payment denial, repayment of fees already paid, mandated educational activities, fines, fraud prosecution, loss of Medicare and/or Medicaid billing ability, and loss of employment.
So what do you need to consider in order to have quality documentation?
(ADVANCE SLIDE.)

8. Considerations for Quality Documentation
Contemporaneous documentation
Accurate documentation
Fraudulent documentation
Inappropriate documentation
Some considerations of quality documentation include:
Your documentation must be contemporaneous – remember, it’s easy to forget what actually happened later
It must be accurate – just the facts, never embellish.
It must never be fraudulent or inappropriate – you could face criminals charges and lose your license to practice
In addition to these tips, I thought I would share with you some basic “Do’s and Don’t” of documentation.
(ADVANCE SLIDE.)

9. Documentation as a Loss Prevention Technique
Documentation Dos and Don’ts:
10 Risk Management Strategies
DO'S
Check that you have the correct chart before you begin writing.
Make sure your documentation reflects the nursing process and your professional capabilities.
Write legibly.
Chart the time you gave a medication, the administration route, and the patient's response.
Chart precautions or preventive measures used, such as bed rails.
Record each phone call to a physician, including the exact time, message, and response.
Chart a patient's refusal to allow a treatment or take a medication. Be sure to report this to your manager and the patient's physician.
Chart patient care at the time you provide it.
If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry.
Document often enough to tell the whole story.
DON'TS
Don't chart a symptom, such as "c/o pain," without also charting what you did about it.
Don't alter a patient's record--this is a criminal offense.
Don't use shorthand or abbreviations that aren't widely accepted.
Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
Don't give excuses, such as "Medication not given because not available."
Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud
Next we will go over 10 Risk Management Strategies
(ADVANCE SLIDE.)

10. Do not cross out an error with more than one line.
Risk Management Strategy 1
Do not erase.
Do not use “white out”.
Do not cross out an error with more than one line.

11. Risk Management Strategy 2
Record only the facts.
Document only observed behavior.
Document healthcare services rendered.

12. Do not write critical comments. Do not document your opinions.
Risk Management Strategy 3
Do not write critical comments.
Do not document your opinions.
Writing comments or your opinion could be considered prejudicial or sarcastic and can be held against you if your notes were ever called into question.

13. (03/31/09 - 7:50AM - Jane Doe, BCCNS)
Risk Management Strategy 4
Begin each entry with the date and time and end each entry with signature and title.
Example:
(03/31/09 - 7:50AM - Jane Doe, BCCNS)

14. Do not leave blank spaces.
Risk Management Strategy 5
Do not leave blank spaces.

15. Record all entries legibly and in ink.
Risk Management Strategy 6
Record all entries legibly and in ink.

16. Avoid generalized phrases such as "bed soaked" or "a large amount."
Risk Management Strategy 7
Avoid generalized phrases such as "bed soaked" or "a large amount."
Be specific by writing specific, accurate descriptions. For example, bright red blood, 18-inch diameter on linens from wound.

17. Risk Management Strategy 8
If an order is questioned, document that clarification was sought and discussed.
Always include the time and date, the person, or person with whom you spoke, and the agreed plan of action for patient care.

18. Document only your own observations and patient services rendered.
Risk Management Strategy 9
Document only your own observations and patient services rendered.
Never chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.

19. Risk Management Strategy 10
Do not permit any visiting relative or other third-party access to the patient care record.
This violates your patient’s privacy and violates HIPAA. The only exception to this would be if you patient was a minor or if your patient had named another person as their legal proxy. Remember, if you are unsure, ask your supervisor.
These risk management strategies are good for your to review periodically to help minimize your risk where documentation is concerned.
So now we need to ask ourselves, what are some of the major challenges that we may encounter?
(ADVANCE SLIDE.)

20. Communication Challenges
Attributes:
Factual
Accurate
Current
Confidential
You are faced with several communications challenges. You have to be sure that all of your documentation comes across as:
Factual
Accurate
Current
Confidential
Some other reporting challenges exist because…
(ADVANCE SLIDE.)

21. Reporting Challenges Oral Report Documentation/Written Report
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.
Nurses must communicate information about clients to other healthcare professionals. Getting the oral reports as well as written charts that occur at changes of shift to come across accurately in your documentation can be a difficult and at the least challenging.
Busy nurses today are faced with many issues that could potentially hinder these efforts.
Several formats of documentation have been developed in order to tackle these communication challenges. Each type has its own strengths and weaknesses.
(ADVANCE SLIDE.)

22. Documentation Techniques Strengths and Weaknesses
Several documentation formats are currently used in nursing.
Each has its own advantages and disadvantages for helping the nurse document patient care.
The nursing department of each hospital or agency has to decide which format best meets its professional responsibilities and patient needs. \
Because there is more than one way to document patient care, you may even find different documentation formats within a facility.
Nursing documentation systems consist of a combination of flow sheets, graphic records, and narrative notes. These forms are designed in many ways and are used differently.
Let’s take a look.
(ADVANCE SLIDE.)

23. Documentation Methods
Charting by Exception
FOCUS
Narrative
SOAP
Electronic
Let’s look at some of the frequently used documentation formats.
Now let’s go over some of the strengths and weaknesses of each type.
(ADVANCE SLIDE.)

24. Documentation Methods
Charting by Exception
What is Charting by Exception? Nurses using this documentation format only document unusual events or changes in the patient’s condition. Care activities are assumed done unless charted otherwise. Often, it includes the use of checklists or flow charts that list standards for assessment and care; nurses check the items off to acknowledge that they were performed. When the standard of care is not implemented, the nurse inserts an asterisk, followed by a narrative note to explain the situation. What are some of the strengths related to this type of charting?
Strengths: Noted strengths of the Charting by Exception documentation format include the following:
Sets standards for assessment and care
Has guidelines printed on the form
Promotes uniform nursing practice
Makes abnormal trends obvious
Highlights abnormal data and makes it retrievable
Isn’t obscured by normal data
Reduces charting time and requires fewer pages
Weaknesses: Noted weaknesses of the Charting by Exception documentation format include the following:
Progress notes
May be very brief since they depend a lot on flow sheets
Have large blank areas
May intentionally omit routine care
CBE notes can’t be used in multidisciplinary charting
They take a major time commitment to develop
They require in-depth training
All stages of the nursing process are not always evident—especially nursing judgments or evaluations
Isolated or unexpected events aren’t documented
The care plan isn’t always revised
Preventive/wellness issues aren’t addressed
Predictable defined outcomes are required
It can be difficult to ensure completeness
It’s difficult to automate this charting format
This format also includes all the problems inherent in the SOAP format (will be discussed later)
Users of this format report problems with double documentation
Information repeated on nurses’ and doctors’ orders, flow sheets, and SOAP notes
Subjective and objective information repeated on flow sheets
The assessment and plan of the SOAP notes may be on the plan of care
(ADVANCE SLIDE.)

25. Documentation Methods
FOCUS
What is FOCUS documentation? This format is designed to encourage a more positive perspective on patient care, rather than highlighting patients’ problems and negative developments. FOCUS uses three columns: Date/hour; Focus; and Progress notes. In the Focus column, the nurse enters the area of the patient’s care or condition that is being recorded. The progress notes column includes three areas for entry: data, action, and response; for this reason, the progress notes are sometimes referred to as DAR. Let’s talk about some of the strengths of this type of charting.
Strengths: Noted strengths of the FOCUS Charting documentation format include the following:
Progress notes are structured.
It promotes the use of the nursing process and stresses the evaluation component.
It’s easy to track a particular problem.
It promotes analytical thinking.
It works in most clinical areas.
It encourages addressing the patient’s concerns, not just the problems.
It can address health promotion and wellness.
The structure is flexible.
It’s easy for others to understand.
The language and process are uncomplicated.
It’s not restricted by a problem list.
The format can be automated.
It can be used in multidisciplinary charting.
Now let’s talk about some of the Weaknesses of FOCUS charting. Noted weaknesses of the FOCUS Charting documentation format include the following:
It changes the nurse’s thinking patterns.This is a short-term weakness until the nurse adjusts to this format.
It requires monitoring to ensure that practitioners follow up on responses.
Some difficulty is evident in categorizing data and identifying responses.
Terminology may be inconsistent between the FOCUS column and the way the information is noted in the care plan, or from one note to the next.
Progress notes may evolve into narrative format.
(ADVANCE SLIDE.)

26. Documentation Methods
Narrative
This is a broad category that can encompass many variations. In general, narrative format is a chronological account of events in a free-form, sentence-based structure. In some cases, the narrative format may include columns or sections to organize information, i.e., treatments, nursing observations, comments, etc.
What are some of Narrative Charting’s Strengths? Noted strengths of the narrative documentation format include the following:
Is a simplified method
Allows the author to control what is said
Promotes chronological documentation—easy to document and track timing of events if documentation is done correctly
Works in all clinical environments
Is easy to teach or learn
Requires no special form—other than blank paper
On the other hand, narrative charting has some Weaknesses too. Noted weaknesses of the narrative documentation format include the following:
The author is given no guidance about what to say.
The author must learn through experience, decide what is important to document, and develop his or her own system for organizing a note.
This freeform can produce notes that could be any of the following:
Fragmented
Disjointed
Non-informative
Rambling and subjective
Inconsistent with what is documented from one author to the next
Too wordy—making it difficult to pick out patient trends and problems
This format requires a lot of time to personalize data for each patient.It’s difficult to retrieve information, since everything must be read to find a certain fact.
It's difficult to retrieve information, since everything must be read to find a certain fact.
The patient outcomes may not be consistently documented, so it becomes hard to track progress or identify lack of progress.
(ADVANCE SLIDE.)

27. Documentation Methods
SOAP
SOAP stands for subjective, objective, assessment, and plan of care. The acronym is intended to prompt nurses to remember all four components in each interaction with a patient: subjective and objective observations, their assessment of the patient, and their plan for intervention and follow up. The subjective observations spotlight the main areas of concern, mainly as expressed by the patient. Documentation of direct patient quotes is encouraged. Objective observations include data from appropriate diagnostic tools and from nurses’ assessment skills. A problem list, recording each health issue under care, is often used with this format.
Noted Strengths of the SOAP documentation format include the following:
They address specific problems.
The structure gives guidance, so information is presented in an organized manner.
The structure of these notes guides the nurse’s thoughts to include the patient’s thoughts or concerns as well as data the nurse has about the problem, assessment, planning of care, evaluation, and revision.
The notes are organized the same from author to author.
The problem list is helpful in these ways:
To alert all caregivers about problems being addressed
To ensure that all problems are addressed
To facilitate data retrieval about a particular problem
Notes show the following:
Continuity of care
Evaluation and resolution of problems
The format promotes documentation of the nursing process.
It eliminates nonessential data
Noted Weaknesses of the SOAP documentation format include the following:
This format is difficult to use when either of the following is true:
There is a fast-paced change in the patient’s condition.
The problem list is not used or kept current.
All components of the note are not used.
Routine care is difficult to document and may not be reported if flow sheets are not used.
Frequent repetitive charting is necessary, since data may relate to more than one problem, and the plan must be in the note and on the plan of care form.
Many people have difficulty deciding where information needs to be placed—is it subjective or objective data? Is the data assessment or evaluation?
This format is time-consuming to write and read due to the repetitive charting.
 SOAP notes are extremely difficult to work with for nurses who have 8 to 12 hours of constant contact with a patient. They are best used in clinical situations where nurses make summary notes for a day, week, or month at a time.
The format isn’t suited for fast patient turnover.
(NOTE: to continue with the SOOOAAP section, go to next slide)

28. Documentation Methods
SOAP (SOOOAAP)
Continue with the SOOOAAP discussion.
NOTE
An extension of the SOAP note is the SOOOAAP note. SOOOAAP selectively expands SOAP by embedding it with easy-to-remember, risk-reduction techniques. This documentation technique can help to improve communication, enhance patient care and decrease your risk of being charged with malpractice. SOOOAAP includes not only subjective and objective information but also the opinion, options, advice and agreed plan as noted by both the provider and the response of the patient and/or caregiver. This format encourages two way communication, patient participation and informed consent of the patient. Moreover, the note keeps a record of the patient’s acceptance of the responsibility for following through with the healthcare plan.
The subjective data included should be driven by patient quotes to demonstrate your attention to the patient, and it should highlight main areas of concern. Objective information should include observed events using assessment skills and appropriate diagnostic tools. Concerns related to tool validity should be indicated in the note (i.e. a questionably accurate blood pressure cuff or a poor fitting cuff). Document if a chaperone was present during an exam when sensitive procedures are being performed (i.e. breast exams). Choose your words carefully and avoid judgmental or potentially anger-provoking descriptors of individuals.
The opinion section is similar to assessment but is more comprehensive in that it reviews the data that supports your assessment and provides a rationale for care decisions and recommendations. It is appropriate to let patients and families know that the diagnosis may not be definitive, but that it is a work in progress. You may think the pain, for example, is normal related to a surgical intervention, but you inform the patient that you will give an appropriate dose of pain medication and re-evaluate in 1 hour. Following opinion, the options of care should be delineated and there should be documentation that the patient has agreed or disagreed with what you have said. In cases where a patient refuses treatment, document that he or she understands the implications of refusal.
The next section of your note should focus on your advice to the patient. This is where the provider has the opportunity to share expertise and help guide the patient’s choice. Document your reinforcement of the principal that you are providing information and advice, and allowing and encouraging the patient to make his or her own decision about care. Continually document health promotion recommendations and prevention techniques (i.e. smoking cessation and exercise), whether or not these are related to the presenting problem. This provides evidence of your concern and interest in the whole person.
Finally, document the plan that has been agreed upon between you and your patient. For example, indicate that the patient/provider interaction resulted in a decision to recheck blood pressure tomorrow and then refer for further treatment if the blood pressure is still high. Indicate if the patient understands and agrees with the plan. When medications are prescribed, document that the patient has been instructed on use of the drug and he/she has provided evidence of understanding of the medication treatment plan.
(ADVANCE SLIDE.)

29. Documentation Methods
Electronic
More and more facilities and practices are using technology to manage patient charts. These electronic
medical records (EMR) systems run on a variety of hardware and follow a variety of formats, and the
specifics of navigation and data entry vary by system. But in general, they allow patient charts to be
created, updated, stored and retrieved via computer.
Strengths: Noted strengths of computer charting include the following:
Charting is legible.
Several people can have access to the same record at the same time.
Prompting is available to remind the person charting about what to chart. <
All changes to the record can be tracked.
The system can be modified to meet facilities’ particular needs.
Notes can be organized the same from author to author.
You always know where the chart is.
This method promotes documenting the nursing process.
It decreases problems in maintaining adequate charting forms and supplies.
Weaknesses: Noted weaknesses of computer charting include the following:
The facility must make a major cash investment for equipment, software, and training.
Many people need to be trained to use a computer and to overcome their fear of computers.
If the hardware or software crashes, you lose access to the chart.
This method requires a major psychological change for staff. They must overcome their fear of computers and must adjust how they work and organize their time.
Documentation may be inaccurate if the practitioner doesn’t carefully read each phrase picked from a menu.
So now we have reviewed the common charting formats, let’s move on to the second powerful tool we will talk about today.
(ADVANCE SLIDE.)

30. Effective Risk Management Strategies
Comply with Nurse Practice Act
Practice Competent Nursing
Comply with Policies and Procedures
Follow Appropriate Incident Reporting
The following are some good risk management techniques to remember:
Follow your states Nurse Practice Act. Understand the Act and always be aware of changes made to it.
Practice Good Nursing – always be kind and caring, that will go a long way towards making your job easier and your patients happier.
Comply with Policies and Procedures of your facility. Like the Nurse Practice Act, always be aware of any changes made to your facility’s guideline.
Follow Appropriate Incident Reporting as dictated by your facility
Remember, with incident reporting…
(ADVANCE SLIDE.)

31. Incident Reporting
Losses can be reduced by a timely, prudent, and compassionate response to an incident!
It can not be stressed enough that losses can be reduced by a timely, careful, and compassionate response to an incident. It can help minimize the damage caused, protecting your patient and yourself.
So what else can you do to properly report incidents?
(ADVANCE SLIDE.)

32. Learn Your Organization’s Guidelines
Examples of Reportable Incidents
Patient falls
Medication errors
Equipment failure
Complaint by patient, family, visitor
Treatment-related injuries
Missed/incorrect diagnosis
Employee exposures
Knowing and following your institution’s guidelines exactly will be the best way you can keep yourself free from reporting error.
Some examples of reportable incidents include:
Any time a patient falls
Any medication errors committed by you or that you found
Equipment failure
Any complaint by patient, family, or visitor
Any treatment-related injuries
Any Missed/incorrect diagnosis
Employee exposures such as employee slips, if an employee is hurt lifting a patient, exposure to harmful substances, and many others
What are some things to remember with incident reports?
(ADVANCE SLIDE.)

33. 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.
It is important to remember to be alert and report ANY out of the ordinary occurrences, even if you think that they are harmless. Document only the facts without drawing conclusions or including your own impressions. Report any out of the ordinary incident within 24 hours of its occurrence.
What steps can you take to assure quality in any investigations that occur at your facility?
(ADVANCE SLIDE.)

34. QUALITY MONITORING Participate in investigations.
Maintain confidentiality of all information.
In order to assure quality in your work, be an active participant in any investigation to which you are related. Be sure to keep confidential anything that occurs during or related the investigation.
Now let’s take a look at a relatively new method being employed by facilities around the country – open charting.
(ADVANCE SLIDE.)

35. 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
Open charting can also be referred to as “Shared Medical Records” and is a method currently employed by a number of hospitals in the United States. While the information contained in a patient’s charts legally does in fact belong to the patient, there are times when it is discouraged for a patient to review his or her own chart, and when they do review the material in their chart it is often after they have already been discharged. Open charting is a method devised to encourage a patient to be involved in his or her own care, to review the notes made by their healthcare providers and to ask questions about the care being provided during the time when the patient is in the hospital or facility and being cared for.
Open charting forces the healthcare provider to be more meticulous about their documentation. If the facility uses handwritten notes, then providers are more careful about legibility, handwriting, and using appropriate abbreviations, knowing that the patient will be accessing the notes. It also encourages the healthcare provider to remain factual and to avoid making generalizations or subjective statements. This system might also make the patient feel more included and well-cared for.
On the other hand, employing a method like this can take up a lot of time. And in many situations, hospitals and facilities are already understaffed and do not have more time to devote to going over charts with every patient and patient’s family. A method like this might also cause patients to question and second-guess the care that they are receiving, causing legal issues down the road.
Next we will talk briefly about the third effective tool you can use to protect yourself and minimize your loss.
(ADVANCE SLIDE.)

36. Documentation Examples
Let’s go over some real life documentation samples, and discuss how they could be improved upon.
(ADVANCE SLIDE.)

37. NOTE: Ignore the names that were crossed out (that is to done to protect the guilty)!
This example demonstrates numerous “don’ts” for charting legalities.
The FHT number & deceleration minutes were blacked out and unreadable. If something is in error, only one line should be drawn through the word(s) and the word “error” written above the strike-out with your initials. Can’t read numbers well on this document. This leaves the impression that items were changed (perhaps at a later date) to cover up something going on with patient.
If charting does not reach the end of a line, a line should be drawn through the blank space to the end signature, as done in the 1430 last line.
This charting is also very sparse with data and analyses, including:
Incomplete data regarding fetus and mom assessment.
What were results of enema given? How did mom/fetus tolerate enema?
Did membranes rupture on their own?
What did the supervisor say/do when notified?
What information was given to MD & Supervisor?
What type of “monitor” is in place? FHT for fetus or monitor for Mom?
Judgmental charting: “Dr. _________finally arrived.” “Husband is really upset with doctor who said…..”
4. There is no thorough assessment of mom/fetus upon admission or prior to going to OR. Don’t have a good “picture” of what this mom looks like, what she is saying, how she is breathing, complaints of pain, color, pulses, circulation, vaginal bleeding/discharge, etc.
Let’s see the next sample.
(ADVANCE SLIDE.)

38. This is an overall example of one nurse that did a very shoddy job of taking care of her patient!
Never chart “Patient had a ‘good’ night.” Only the patient can say whether their night was good or not. This is judgmental charting on the part of the nurse. It also does not tell the reader anything at all about how well the patient slept; were they complaining of pain/discomfort any time?; did they need to void during the night?; etc.
Notice the sequence of charting. The 0300 (3:00am) chart note was put in after the 0600 (6:00am) note. This always looks as though the nurse just realized she forgot to chart during the night. What it really looks like is the nurse never looked in on the patient during the night. Don’t chart “Pt. asleep.” Need to describe what you see….patient eyes closed, breathing evenly, not moving, etc.
Is that 0830 (8:30am) or 0730 (7:30am)? What is BS? Bowel sounds? Breath sounds? Let’s give a little data here! Describe the sounds; what you hear, where, loud or soft, etc. There is also no signature next to this charting.
0800 (8:00am) Oh gosh…now we see that the patient is a baby. All the more reason to have more detailed charting throughout the night and day.
Baby took 60 cc of what well? Formula? Breast milk? Beer??? Did Dr. Smith pass the large stool? Did Dr. Smith cause the baby to pass a large stool?
Patient without complaints? Can this baby actually talk, or are we making a judgment that because the baby didn’t cry, it wasn’t in pain?
What time is 250? Assume it is 2:50pm, but that would be 1450 if charting in military, 24 hour time.
Where is this wound? Describe the puss. Describe the dressing; amount, smell, color, consistency, etc. What type of dressing was put on and where? How did patient tolerate dressing change? Anyone notified of this puss? I hope there is a temperature charted somewhere.
Also, many blank lines skipped in charting that is a no-no. Don’t leave space for others to add in charting.
Let’s hope that this is a fabricated charting example!
Maybe the next one will be better!
(ADVANCE SLIDE.)

39. This looks as though we have a little battle going on between the day and night shifts! Don’t take out your frustrations in patient documentation! Don’t make judgmental comments in charting!
Mrs. Jones deserves to have better care and better charting! Can’t get factual information from this note regarding how or when Mrs. Jones fell or her injuries/condition. Did she state that she called for help, or did this nurse hear her? We need a thorough assessment of patient documented with findings from fall. What was reported to supervisor and what was supervisor’s response?
Need to complete an incident report regarding the other issues of patient fall with staffing situation. Not in patient chart. Only the facts as they relate to the patient should be in the chart.
Looks as though no one checked on Mrs. Jones from 3:50am until 7:00am! No description of patient. No assessment. Again, judgmental charting toward night shift.
This charting will be devastating for the nurses/hospital if this goes to court! Negligence is written all over this example!
Let’s try the next example.
(ADVANCE SLIDE.)

40. This is an example of decent charting, but it needs to go further to paint that accurate picture of the patient.
Do we know where this patient had pain? How intense was the pain? Was it graded on a pain scale? How long as this temperature been elevated? Just how low is the blood pressure? Just how high is the heart rate?
Did Dr. M order the fluid bolus? How much and what fluid? Over what period of time.
This charting lists all these activities as having occurred at 2330 (11:30pm). It took time to get the physician called, get the orders, obtain the fluid, deliver the fluid bolus, obtain the pain medication and antibiotics and deliver them. These did not all occur at 11:30pm! Important to remember to chart the time that the assessment was made, the physician was called, the fluid bolus was given, the pain meds and antibiotics were given. In a court of law, this will appear as sloppy charting that the nurse did all at one time. It may be construed that the nurse did not remember the times these things were actually accomplished. This will diminish the nurse’s credibility.
Let’s try an example that shows how charting can be easily misread.
(ADVANCE SLIDE.)

41. These are 3 good examples of how medication orders can occur through misread or illegible written orders.
Is the first order to:
Give 3 drops of Ampicillin ointment in each eye every day?
Give 3 drops ampicillin (or amps) ointment in both eyes four-times per day?
Who knows? Very messy handwriting. Uses abbreviations that are not commonly known.
Is this order for .1 mg Morphine Sulfate IV Push now? Or
1 mg Morphine IV piggyback now?
Or what?
Always precede a decimal point with a zero. Should read 0.1mg.
Make certain IVP is spelled out.
Is this order to flush a catheter with 5 cc’s of ½ Normal Saline every hour? Or
Flush catheter with 5 cc’s ½ normal saline at bedtime? (qhs)
Very unclear. Needs to spell out which catheter! (IV or Foley)
Physicians have been known for their sometimes sloppy handwriting. Let’s see an example of how this can affect you.
(ADVANCE SLIDE.)

42. About all you can say for this order sheet is that you better just tell the ordering physician to come back to the unit in person & rewrite the entire order sheet! Extremely bad handwriting that can be misinterpreted.
Was the Ancef or MSO4 given in the OR?
What is the “appropriate dose” of Tylenol for this patient? MD needs to order that, since this is a child.
What type of “spasms” is the Valium ordered for? Bladder? Musculo-skeletal?
Is that an order for a wheelchair on the chart? Isn’t the patient ordered to be on bed rest?
What strength of Albuterol updrafts are we giving to this child?
We can hep loc the IV when the patient is +1 po. What does that mean for this child?
Many examples that can be misinterpreted. Don’t be afraid to ask for clarification of all!
How about some samples of good charting?
(ADVANCE SLIDE.)

43. These two charting examples are very detailed
These two charting examples are very detailed. They delineated what the nurse did in response to the patient’s symptoms. These are examples of good charting. It is just a bit difficult to read handwriting.
(NEXT SLIDE.)

44. 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.”
Note to the Educator:
In order to bring some levity to the presentation, we have provided a list of charting “bloopers” that have occurred. You can choose to break down these bloopers and integrate them into the presentation itself, keep them at the end, or not use them at all.

45. THE END