1. Nursing Documentation in the Medical Record
Back to Basics

2. WCHOB Case # 1 Newborn Infant
Allegation: we failed to properly diagnosis and treat hypoglycemia
Injury: blindness and mild developmental delays
Evidence: Parents testified that nursing staff did not bring infant to mom for regular feedings. There was no documentation in chart regarding feeds. It looked like infant was not fed for 12 hours.
Verdict: Settled out of court

3. WCHOB Case #2 Decubitus
Allegation: Nursing staff failed to prevent decubitus of the left heel and knee of 14 yr old receiving epidural pain medication following a urological procedure
Injury: Stage 3 –4 decubitus of the left heel which required skin grafting. Stage 1 decubitus to left knee.

4. WCHOB Case #2 Decubitus
Evidence: No documentation that the patient was repositioned every 2 hours while the epidural was running as required in the epidural policy. After decubitus was identified, there was no documentation that the patient was checked or repositioned. Mother testified she never saw a nurse reposition her daughter while the epidural was running.
Verdict: Settled out of court

5. WCHOB Case #3 Spinal Injury
Allegation: WCHOB failed to recognize and appreciate the deterioration of the patient’s neurological status and failed to correctly diagnose the spinal fracture
Injury: Paraplegia
Evidence: Poor documentation created a very confusing picture as to when the patient’s neurological deficits were first noted. ED nurses note lacked documentation of any physical assessment by the nurse.

6. WCHOB Case #3 Spinal Injury
Evidence: Nurses notes indicate in neuro section that patient had “no response” to lower extremity movement for 2 hours with no intervention by the nurse. Skin assessment section has a “C” documented for cold. This appears to be written over a “W” for warm. (This may not be significant, but it calls into question the integrity of other entries in the chart.) It also appeared that this was charted to agree with the resident’s note that the skin was cold.

7. WCHOB Case #3 Spinal Injury
Evidence: Nurses notes were timed but not in order:
7pm- Patient had minimal movement of her toes.
Next entry (timed 6:40 pm)- Patient unable to wiggle toes, does not respond to touch on bottom of feet, legs are floppy. Patient could not initiate any movement.
Next entry (timed 7:30 pm)- Physician in to assess patient
Verdict: Settled out of court

8. Purpose of the Medical Record
Communication among caregivers about patient condition, care and response to treatment
Evidence in legal proceedings
Reimbursement
Data for research studies
Planning and implementing quality improvement measures

9. Legal Considerations What catches an attorney’s eye?
Pages without patient identification
Dates and times that don’t correlate with the remainder of the chart
Changes in slant, uniformity, or pressure of handwriting

10. Legal Considerations What catches an attorney’s eye?
Changes in ink or pen on the same entry
Erasures or obliterations
Entries written over previous entries to correct or change it

11. Common Documentation Errors
Omissions
Include all facts needed to provide care to the patient. If it is not documented, you did not do it!
Personal Opinions
Record only factual and objective observations. Include patient statements.

12. Common Documentation Errors
Vague Entries
Instead of “Patient had a good day”, state why: Patient denied having pain.
Late Entries
Identify as late and enter date and time. Document date and time you are relating back to (04/01/07 for 3/31/07).

13. Common Documentation Errors
Improper Corrections
As per Kaleida Health Policy MR-16: A single line should be drawn through erroneous information. The individual making the correction should sign, date and time the correction. Do not use correcting fluid. Do not obliterate the original entry.

14. Common Documentation Errors
Unauthorized Entries
Don’t document for anyone else
Erroneous Abbreviations
See next slides
See Kaleida Health Policy MR.4 Use of Abbreviations
Illegibilty and lack of clarity
Write so others can read your entry. Use correct spelling.

15. UNSAFE ABBREVIATIONS Updated By JCAHO May 2005
UNSAFE ABBREVIATIONS Updated By JCAHO May 2005
Abbreviation
Intended Meaning
Error
Recommendation U
Units
Misread as 0, 4, or cc (e.g. An order for 10 U of insulin can be misread as 100)
Write out “units” IU
International unit
Mistaken as IV (intravenous) or 10(ten)
Write ”unit”
QD, QOD
Once daily, or once every other day
Mistaken for each other. The period after the Q can be mistaken for an “I” and the “O” can be mistaken for an “I”
Write “daily” or “every other day”
Trailing zero (e.g. 1.0 mg)
1 mg
Misread as 10 mg
DO NOT USE trailing zeros after a decimal point
Lack of leading zero
0.1 mg (e.g. .1 mg)
Misread as 1 mg or 11 mg
Always use a zero before a decimal point
MS, MSO4, MgSO4
Morphine Sulfate or Magnesium Sulfate
Misread as the other
Write out drug name

16. The following abbreviations are strongly recommended not to be used in medication documentation
BIW
TIW
Two times a week
Three times a week
Misread as two or three times a day
Specifically write out “two” or “three times a week”; or write out specific days medication is to be administered (e.g. Q Mon, Wed, Sat) Ug
Mcg
Misread as mg, or u misread as 0 units read as grams
Use “mcg” instead
AU, AS, AD
Both ears, left ear, right ear
Misread as OU, OS, OD
Specifically write out intended route of administration
OU, OS, OD
Both eyes, left eye, right eye
Misread as AU, AS, AD
X3d
For three days
Misread as for three doses
Write out “for 3 days”
Practitioners are strongly encouraged to write out all medication names to avoid potential confusion.

17. Documentation on the Medication Administration Record
Blue or black ink, unless otherwise specified.
Practitioner’s full legal signature/title must be in the medical record
Corrections as per KH Policy MR.16
Must be placed in patient record upon discharge

18. Documentation on the Medication Administration Record
Scheduled Medications Medication Administration Record
Use for all medications given on a continuous basis
PRN Medication Sheet
Use for all medications given on a prn basis
Special Medication (STAT) Sheet
Use for all STAT, short series, one time only, or pre-op/test medications

19. Pain Documentation Use approved pain scale (CRIES, FACES or PAINAD)
Include: location, intensity, quality, onset/duration/variation, aggravating or relieving factors
Determine how pain has affected activities
Establish a comfort function goal (pain rating that allows the patient to participate in recovery and quality of life activities)

20. Pain Documentation
Assess pain as the fifth vital sign, after any known pain producing procedure, with each new report of pain, and WHEN THE MEDICATION HAS REACHED ITS PEAK EFFECT (IV bolus and PCA – minutes, Oral/Rectal – 1-2 hours, IM/SQ – 30 minutes, Epidural or Intrathecal – Fentanyl – minutes; Morphine – minutes)

21. Pain Documentation
Sedation Scale for patients medications that depress the central nervous system:
S = Sleep, easy to arouse
1 = Awake and alert
2 = Slightly drowsy, easily aroused
No action required

22. Pain Documentation
Sedation Scale for patients medications that depress the central nervous system:
3 = Frequently drowsy, drifts off to sleep during conversation. Decrease opioid 25 – 50%, consider non-opioid such as acetaminophen or NSAID
4 = Somnolent, minimal or no response to physical stimulation. Consider Naloxone as per Kaleida Health policy CL.9. Notify MD, monitor sedation and respiratory status closely until sedation is less than 3.

23. Conclusion
Falsifying or altering medical records is a misdemeanor under some state penal codes. It is also professional misconduct and reportable to the Nursing Board.
Do not write in advance.
Document the name of the physician/resident you spoke to.

24. Conclusion
Be definite and specific so that information is clear to any doctor, hospital staff of jury.
Five years later at trial, you will not remember exactly what you meant.
Don’t skip lines between entries or leave spaces.
Don’t wait until the end of the shift to chart. Don’t rely on your memory.

25. References
Austin, Sally. “Ladies and gentlemen of the jury, I present…the nursing documentation.” Nursing (1):56-63, January 2006
Wetter, Dana. The Best Defense is a Good Documentation Offense. Corexcel.
NCLEX – RN Review Made Incredibly Easy!. 3rd Edition Lippincott, Williams and Wilkins.
Kaleida Health Policy TX.4 Pain Management- Adult/Child
Kaleida Health Policy TX.IV’s & Meds.1POL Transcription of Medication Orders and Use of the Medication Administration Record
Kaleida Health Policy TX.IV’s & Meds.2.GDL Guidelines for Completing Scheduled Medications Medication Administration Record (MAR)
Kaleida Health Policy TX. IV’s & Meds.5.GDL Guidelines for Completing Special Medication Sheet
Kaleida Health Policy #GDL_11 Documentation of Adult/Pediatric Patient Care – Policy
Kaleida Health Policy MR.4 Use of Abbreviations
Kaleida Health Policy MR.16 Documentation Requirements in the Medical Record