Documentation Issues with Electronic Medical Records Suzanne McMurtry Baird, DNP, RN Clinical Nurse Specialist The Woodlands, Texas suzannebaird@att.net

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

Documentation No documentation Poor documentation Confusing documentation Conflicting documentation Missing documentation

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

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

Documentation Data from external sources flow into EMR EFM Vital signs Hemodynamics Validation of data Is the information accurate?

Documentation Myth “If it wasn’t documented…… it wasn’t done”

Documentation – Example What are the components of documentation that need to be included in regards to the EFM strip?

Documentation Example “Doctor aware. No orders received”

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.

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.

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

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

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.

EMR Wish List

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

Documentation - Safe Checklists Time out Quality and safety data

Documentation - Safe Quality Measures “We measure what we value and we improve what we measure” AWHONN

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.

Documentation - Safe Order Entry Clear Concise Match policy/care guidelines

Documentation - Effective Trending of Data Vital Signs Labs Intake and Output

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?

Documentation - Effective Essential categories of assessment Legal Issue: Assessment parameters are incomplete or not available for documentation

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

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

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

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

Documentation – Patient Centered

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

Documentation - Efficient

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

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!

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?

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

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

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

Case Studies

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

Note: 39 week Hard Stop

Checklist

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

Case Study - 1840 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”

Oxytocin In-Use Checklist

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

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

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

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

Case Study – RN No interventions Anticipation Oxygen not started Pitocin remained at 22 mu

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”

Case Study – Newborn Outcome Birth asphyxia diagnosed Developmental delay

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