implication of documentation in nursing 1

5/14/2018 Implication of Documentation in Nursing 1 - slidepdf.com

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S.L.Smith

IMPLICATIONS OFIMPLICATIONS OFDOCUMENTATION INDOCUMENTATION IN

NURSINGNURSINGPresented by Sophia SmithPresented by Sophia Smith

U.H.W.I. NURSING STAFFU.H.W.I. NURSING STAFFDEVELOPMENT DIVISIONDEVELOPMENT DIVISION



Charting with a jury in mindCharting with a jury in mind

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IMPLICATION OFIMPLICATION OF

DOCUMENTATION IN NURSINGDOCUMENTATION IN NURSING

YOU WAKE UP in a cold sweat afterdreaming that you’re the defendant in amedical malpractice case.

The plaintiff’s lawyer was about to point outthe flaws and gaps in your documentation.Thankful it was only a dream.



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OBJECTIVESOBJECTIVES

At the end of this ninety (90) minute session At the end of this ninety (90) minute sessionparticipants will be able to:participants will be able to:

Define the terms documentation, record,Define the terms documentation, record,report and client.report and client.

Indentify the reasons for documentation.Indentify the reasons for documentation.

Discuss the principles of documentation.Discuss the principles of documentation.

Describe 2 societal factors that affect legalDescribe 2 societal factors that affect legaldocumentationdocumentation



OBJECTIVESOBJECTIVES

Discuss the nursing implications of Discuss the nursing implications of documentation.documentation.

Identify measures to ensureIdentify measures to ensuredocumentation meet legal standards.documentation meet legal standards.

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DEFINITIONSDEFINITIONS

Documentationocumentation is any written oris any written or

electronically generated information aboutelectronically generated information about

a client/ patient that describes the care ora client/ patient that describes the care orservice provided to that client (CRNBC,service provided to that client (CRNBC,

2007).2007).


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DEFINITIONSDEFINITIONS

Recordecord is the information set down inis the information set down in

writing.writing.

Reporteport is spoken or written accountis spoken or written account..

Client refers to individuals, families,

groups, populations or entire communities

who require nursing expertise.



REASONS FOR DOCUMENTATIONREASONS FOR DOCUMENTATION

To facilitate communicationTo facilitate communication

To promote good nursing careTo promote good nursing care

To meet professional and legal standardsTo meet professional and legal standards



PRINCIPLES OF DOCUMENTATIONPRINCIPLES OF DOCUMENTATION

IN NURSING.IN NURSING.

Accuracyccuracy ::

- Entries must be accurate. Write only- Entries must be accurate. Write only

observations that you have seen, heard,observations that you have seen, heard,

smelled, or felt.smelled, or felt.

- An observation made by others must be- An observation made by others must be

clearly indentified .clearly indentified .

- Check the spelling, proof read.- Check the spelling, proof read.




IN NURSINGIN NURSING

- Avoid use of abbreviations (other than- Avoid use of abbreviations (other than

those approved and documented in thethose approved and documented in the

organizational policy).organizational policy).





Completenessompleteness ::

-be factual, accurate, true and honest-be factual, accurate, true and honest

record. (including record of late entries,record. (including record of late entries,

changes or additions).changes or additions).

-avoid duplication of information.-avoid duplication of information.





Conciseness:onciseness:

- documentation contain meaningful and- documentation contain meaningful and

relevant information.relevant information.

- include detailed documentation in- include detailed documentation in

relation to critical incidents.relation to critical incidents.





Objectivity:bjectivity:

- When charting subjective findings- When charting subjective findings

identify the source.identify the source.

Organization:rganization:

- Each entry must clearly show a logicalEach entry must clearly show a logicaland systematic grouping of importantand systematic grouping of important

informationinformation



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Timeliness:imeliness:

- Documenting in a timely manner can- Documenting in a timely manner can

help in reducing errors.help in reducing errors.

Legibil ity:egibi l ity:

- Writing must be clear and easily read- Writing must be clear and easily read

byby

others.others.





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Confidential:onfidential:

- access to client information should be to- access to client information should be to

health team persons who are caring forhealth team persons who are caring forthe client.the client.




IN NURSING CONT’DIN NURSING CONT’D

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IMPLICATION OFIMPLICATION OF

DOCUMENTATION IN NURSINGDOCUMENTATION IN NURSING

Societal factors that affect nursingocietal factors that affect nursing

documentation include:ocumentation include:

Increased Consumer Awareness.Increased Consumer Awareness.

Increased Acuity of Hospitalized Patients.Increased Acuity of Hospitalized Patients.

Increased Emphasis on Outcomes.Increased Emphasis on Outcomes.

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IMPLICATIONS OFIMPLICATIONS OF

DOCUMENTATIONDOCUMENTATION

Failure of adhering to the principles of Failure of adhering to the principles of

documentation may be detrimental to thedocumentation may be detrimental to the

patient and thus result in legal nursingpatient and thus result in legal nursing

issues.issues.



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MEASURES TO ENSUREMEASURES TO ENSURE

DOCUMENTATION MEET LEGALDOCUMENTATION MEET LEGAL

STANDARDSSTANDARDS Documenting assessment of the needs.Documenting assessment of the needs.

Documenting purpose, objectives orDocumenting purpose, objectives orexpected outcomesexpected outcomes

Documenting the plan or approach toDocumenting the plan or approach to

care.care.

Evaluation of interventions and outcomesEvaluation of interventions and outcomes




DOCUMENTATIONDOCUMENTATION If you are ever involved in a malpracticeIf you are ever involved in a malpractice

dispute, the patient’s chart will be your bestdispute, the patient’s chart will be your best

friend – or your worst enemy.friend – or your worst enemy.

So ensure each entry is:So ensure each entry is:

FFactualactual

A A ccurateccurate CCompleteomplete

TTimelyimely

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FindingFinding FFlaws in thelaws in the R R ecordecord

Looking forooking for red flagsed flags in the recordn the record

Pages without any patient identificationPages without any patient identification

Notes written with the wrong date or with timesNotes written with the wrong date or with times

An entry written over a previous entry to correct An entry written over a previous entry to correct

or change itor change it

Changes in slant, uniformity, or pressure of Changes in slant, uniformity, or pressure of

handwriting or changes in ink or pen on thehandwriting or changes in ink or pen on thesame entrysame entry..



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FindingFinding FFlaws in thelaws in the R R ecordecord

Looking forooking for red flagsed flags in the recordn the record

Any erasure or obliterations Any erasure or obliterations

Pathology report or diagnostic test findingsPathology report or diagnostic test findingsthat don't correlate with physical assessmentthat don't correlate with physical assessment

findings or that don't show the medicalfindings or that don't show the medical

necessity for a procedure.necessity for a procedure.

Long narrations that don't seem to beLong narrations that don't seem to be

sequentialsequential..





GROUP WORK GROUP WORK

5 minutes5 minutes

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Failure to notify the health

care provider of problem.

The patient Matilda Bennett’s condition wasworsening. Her nurse called the attendingphysician several times to report the

deterioration but failed to document herinitial unsuccessful attempts to reach thephysician.

In a deposition, the nurse testified that

she’d called the physician as soon as shenoted a change in Ms. Bennett’s condition.



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Failure to notify the health

care provider of problems

Scenario

Her nursing documentation indicatedthat the patient’s condition changedfor the worse at 2:40 p.m., but an

attempt to contact the patient’sphysician wasn’t documented until3:45 p.m. The attending physiciancorroborated the nurse’s testimony,

saying that he’d received a call fromher at 3 p.m., but the jury refused tooverlook the lack of documentation





No matter how skilled a nurse you are,No matter how skilled a nurse you are,

poor nursing documentation willpoor nursing documentation willundermine your credibility if you'reundermine your credibility if you're ever involved in a lawsuit.ever involved in a lawsuit.

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S.L.Smith

ReferenceReference

Austin, S. (2006). Ladies and gentlemen of Austin, S. (2006). Ladies and gentlemen of the jury, I present … the nursingthe jury, I present … the nursing

documentation. Retrieved on March 17,documentation. Retrieved on March 17,2011 from2011 from

http://www.nursingcenter.com/prodev/cehttp://www.nursingcenter.com/prodev/cearticleprint.asp?CE_ID=622257articleprint.asp?CE_ID=622257

Bergerson, S.R. (1988). More aboutBergerson, S.R. (1988). More about

charting with a jury in mind.charting with a jury in mind. Nursing Nursing ,,18(4), 50-8.18(4), 50-8.



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ReferenceReference

Carven, R. F. & Hirnle, C. J. (2007).Carven, R. F. & Hirnle, C. J. (2007).

Fundamentals of nursing: human Fundamentals of nursing: human

health and function.health and function. (5(5thth ed.).ed.). Philadelphia:Philadelphia:

Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.

CRNBC. (2003).CRNBC. (2003). Nursing Documentation.Nursing Documentation.

Retrieved on June 8, 2009 fromRetrieved on June 8, 2009 fromhttp://www.crnbc.ca/downloads/151.pdf http://www.crnbc.ca/downloads/151.pdf



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THANK YOU.THANK YOU.

ANY QUESTIONS. ANY QUESTIONS.

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