Legal Documentation Does it tell the story?

The goal of this presentation is to emphasize the importance of accurate, complete and timely documentation

Objectives At the completion of this presentation, the participant will be able to: State the purpose of documentation. Identify 2 items that need to be included in documentation. State how often you should document

Responsibility Healthcare providers have a legal, ethical and moral responsibility to accurately document the care they provide to patients.

Purpose of Documentation The purpose of the clinical record is to provide accurate, concise, comprehensive health information about the residents

Purpose of Documentation Furnishes information on resident care. Helps verify quality care. Assist in the coordination of care. Complies with regulations of the government and accrediting organizations. Provides evidence in a court of law.

Documentation includes… An assessment of the patient’s health status. A plan of care reflecting the needs and goals of the patient. The nursing interventions carried out. The impact of the interventions. Information reported to the physician or other health care providers.

Documentation Documentation must take place on each resident at least every 4 hours. If the resident’s condition has not changed, that still needs to be documented Residents vital signs are within normal limits. No signs or symptoms of pain or discomfort. G-tube and foley catheter patent. No change in condition noted-M.E. Nurse, LVN

What is missing from this documentation? Medical records should be complete: 0200 Mrs. Jones fell out of her bed. B.Brown,RN What is missing from this documentation?

Documentation 0200-Patient was found laying on the floor. Patient states that she needed to use the restroom. Physical assessment reveals a 1” laceration to right forehead. No further injuries noted. Patient is able to move all extremities without difficulty. Family and physician notified of fall. No new orders received. B.Brown,RN

Documentation How good is your memory? Nurse writes: “Patient medicated for pain” 2 years later that nurse gets asked: What kind of pain was the patient having? What medication was given for the pain? Was the pain medication effective? How good is your memory?

What should have been written? Documentation What should have been written? 1-1-09 (1700)-Patient medicated with Tylenol 500 mg one tablet P.O. for right hip pain-mn 1-1-09 (1730) Patient state no further complaint of right hip pain-mn

Documentation Documentation should be complete Entries should be legible Make all entries consecutive and timely

Legibility Must be legible If you don’t know how to spell it, look it up Your signature must be clear with the proper credentials Example: Mary Jane Jones,, RN

Good documentation is.. Factual Accurate Complete Current (timely) Organized

Documentation If it isn’t documented, it didn’t happen Tell the whole story