Unraveling the Mystery of Nursing Documentation

Wanda Sanchez, MSN, RN, MBA, ANP-BCEvangelina Ramirez MSN, RN, CCRN

Clinical Nurse Educator

Documentation

Or….You want this chart to be your friend

Documentation

• Bad documentation can make good nursing look bad and can make bad nursing look even worse.

• Five years from now, you probably won’t remember the patient you had yesterday. All you will be able to depend on is your notes.

• If that statement makes you feel better then you are probably doing a decent job of documenting.

• If that statement gives you the willies, then we need to re-visit your documentation skills

Objectives

• Determine the legal responsibility and accountability of the nurse in documentation.

• Support quality of care through documentation.• Reduce risk in documentation• Validation through documentation• Comparison of paper documentation versus

electronic documentation• How to use the nursing process in documentation• Use of actual case studies to clarify appropriate

documentation.

Significance

• Legal Proof of the nature and quality of care• May be the focus of inquiry in injury, malpractice or

liability claims• Complete records will defend you against

allegations of negligence, improper treatment or omissions in care

What if you see the following charted?

“The patient was LTBB.”

What do you think that MEANS????

LTBB is not an approved abbreviation:

DO YOU KNOW WHAT IT MEANS?

LTBB means:

LUCKY TO BE BREATHING!

WE ARE ALL PROBABLY LUCKY TO BE BREATHING (LTBB)

But we would never chart this (Hopefully)

Has it happened?

Yes it has happened and then it was a mystery to unravel what LTBB actually meant.

Would you as a nurse want to explain in court to a jury that you charted LTBB and then have to tell a jury/judge what LTBB means?

Significance

Failure to document implies failure to provide care

Documentation Provides

• Written evidence of interactions, treatments, procedures and patient’s response to them

• Communication with other health care providers

• Nursing documentation is an important part of clinical documentation and is a fundamental nursing responsibility with professional, legal and financial ramifications.

Objectives in Documentation in Nursing Practice

• To show evidence of provision of quality health care

• Advancement of efficient and effective health services programs

• Creation of a legal record of nursing services/treatments/communications provided to patients.

How Medical Records are Viewed

• There is a presumption that a medical record is accurate if no evidence of fraud or tampering is noted.

• Medical records that are intact, sequential, and organized supports a presumption of “quality care.”

Legal Pitfalls of Improper Documentation

• Faulty record keeping practices;• Absence of information;• Charting after the fact;• Missing records, time gaps;• Vague Entries;• Late Entries;• Improper corrections;

Legal

• Unauthorized entries;• Use of unauthorized medical abbreviations;• Documenting personal opinions;• Writing is illegible• Hospital loses money due to improper and/or failure

to correctly input proper diagnostic codes.

How to Avoid the Legal Pitfalls of Documentation

– Number, Date and Sign all entries;– Write legibly;– Use generally accepted standard medical

abbreviations;– Document immediately or soon thereafter when

caring for your patients;– Document what you see, hear, feel and smell; – Avoid innuendo;

How to Avoid the Legal Pitfalls of Documentation

– Avoid use of liquid paper or correction tape;– Avoid use of pencil;– Do not chart for others;– Enter appropriate codes;– Follow proper policies and procedures for

documentation

How to Avoid the Legal Pitfalls of Documentation (cont)

– Make corrections following appropriate guidelines;– Avoid tampering with records;– Follow hospital policies for handling verbal orders,

telephone orders, etc.– Do not leave blank spaces for others to later add

entries;– After charting, avoid divulging confidential

information to “others.”

How to Avoid the Legal Pitfalls of Documentation (cont)

• Use appropriate punctuation and grammar.• Double check patient information;• If computerized charting is utilized in your

institutions, take measures to safeguard your personal code.

• Maintain patient privacy• Avoid derogatory comments on charting

systems.

GENERAL TIPS FOR AVOIDING LIABILITY

• Maintain prudent documentation and healthcare practices

• Be familiar with policies and procedures re: charting and documentation of your health care facility

• Establish a good rapport with your patients• Write legibly• Document factual information• Write proficiently, use proper grammar and

punctuation.

Assessments

• Full shift assessments should be done at the beginning of the shift and after a fall

• Focused assessments should be done as per your unit protocol every 4 hours in critical care

Narrative charting

• Your first note should be fairly extensive and should “paint a picture” of what the patient status is, your view of their initial assessment, any outstanding or unresolved problems

First note

This is where you document your lines, drips, rhythms, pressures, etc. i.e.

54 year old male in with diagnosis pancreatitis under service Dr. Feelgood. Admitted to hospital and this unit on 12/1/08. Patient awake, responsive, moves all extremities purposefully. Complains of abdominal pain and vomiting. Skin color icteric warm dry. IV’s as follows:

Left subclavian triple lumenNS at 120Dopamine infusion at 7 mcg/kg/minCVP Pressure readings done on 3rd port

Continued

NGT in place, verified though auscultation of air bubble and return of gastric contents. Connected to Low continuous suction draining small amounts green drainage. Foley catheter patent draining clear yellow urine in amounts greater than 30cc/hr

Medicated with Demerol 25mg IV at 0730 for c/o abdominal pain, will recheck in 15 minutes for relief of pain.

More documentation

Don’t forget to write that the Plan of care was discussed with patient and that they agreed to same. Also, note any teaching including content and response and who was the recipient of the information.

Fine ART of NURSING DOCUMENTATION.

• Why do we document?• We document to paint a clear and unbiased picture of

our patient.• We document to pass on important information to our

colleagues.• We use documentation in a collaborative effort to care

for our patient through interdisciplinary teams.• We document to reduce risks.• We document to support quality of care for each patient.• We document to protect our patient and ourselves.• We document to maintain effective communication

among team members.

What happens if we do not document?

• Errors are made.• There is confusion.• We have no record of what happened with our

patient on a shift by shift, day by day basis.• We have no legal basis on which to stand and

support what we as nurses have done to care for this patient.

• We do not effectively communicate.

Your license may depend on good documentation:

Maybe you did what you as a nurse and professional should have done.

The question is: How do you prove it?

The answer is:

• You can not validate nor prove that you did what you were supposed to do unless you documented it.

• This goes along with the tried and true statement of, “If you did not document it, you did not do it.”

The DO’S of charting/documenting

• Make sure you have opened the correct chart.• Make sure you are documenting the

information on the correct patient.• Chart in a chronological manner.• Do not wait to the end of the shift to document

as you will forget something.• Use the nursing process.• For every action there must be an interaction.• Chart the care at the time you give the care.• Document a clear and concise picture.

More documentation

• Don’t forget to write that the Plan of care was discussed with patient and that they agreed to same. Also, note any teaching including content and response and who was the recipient of the information.

DON’T/S

• Do not chart a symptom such as c/o of pain without charting an intervention.

• Do not ever alter a charted document as this is a criminal offense.

• Do not chart what someone else said.• Chart what you know to be a fact as it relates

to your patient.• Do not chart in advance, what if something

happens and you can not complete the care you have already charted?

• Chart in precise language, watch out for unapproved abbreviations and indistinct shorthand.

Common AllegationsMade Against Nurses

Patient Falls Failure to monitor Medication errors/Poor documentation Equipment injuries Failure to follow hospital policies and procedures Failure to ensure patient safety Failure to report a change in patient’s status Explore allegations in the various health care

settings

Factors that PromptFamilies to Sue

Nurse’s attitude is insensitive or he/she ignores a patient’s complaints

Nurse fails to meet patients needs throughout the course of their hospitalization

Nurse is inflexible and does not communicate well with patient and/or family members

Nurse exceeds boundaries and limits of practice

Typical Profile of a Litigious Plaintiff

Openly expresses hostility or anger at members of the health care team

Highly critical regarding all aspects of nursing care

Overreacts to any comments made Blames staff for any and all negative events

which have occurred Has a history of filing lawsuits

Strategies to curtail or prevent suits

Establish a good rapport with your patientsFollow the ANA’s Moral Principles

Respect Autonomy Beneficence Non-Maleficence Veracity and Confidentiality Fidelity and Privacy Justice

Strategies cont.

Instill patient confidence Keep patient and families informed of care

issues Be attentive, sincere and display a genuine

sense of warmth Maintain a professional demeanor at all

times Note: 75% of decisions to sue center on

poor attitudes and poor communication. These are often the most costly civil type actions!

Impact of Standards of Nursing Practice

Standards of Practice serve as a legal yardstick to measuring our course of practice

They serve as “minimum”guidelines for dictating the boundaries of our practice

For legal purposes, they measure the performance of nurses with that of a “reasonably prudent nurse”

Each specialty of nursing may have their own individualized SOP

SOP may change periodically

Standards of Nursing Practice Cont.

SOP are sometimes confused with clinical guidelines or professional performance standards

Note the differences: SOC: are standards used to measure whether

nurses are following the nursing process SOPP: are standards relating to the professional

behavior of nurses Clinical Guidelines: are pt focused and determine

if the nurse is carrying out the recommended course of action

Board of Nurses Standards

RN Board: Section 217.11 of the NPA addresses minimum Standards of Professional Nursing Practice applicable to ALL nurses

Section 217.12 addresses what constitutes “unprofessional conduct” for both RNs & LVNs licensed in Texas

Examples of NPA violations

A nurse’s patient stopped breathing, the nurse left to gather supplies rather than initiate the Code and asks others to begin the Code. Two minutes lapsed from the time pt stopped breathing and when the nurse asked others to initiate CPR

An RN delegated an IM injection to an aide. The RN did not supervise the injection and the pts. sciatic nerve was damaged

Examples Cont.

The nurse was required to visit all home health clients within an allotted time. The nurse ran behind and instead of personally visiting all of the pts, the nurse called the patients. The nurse then documented that he had visited all the pts and thus Medicare was “fraudulently” billed for all these visits

A nurse was ordered to administer Valium IV. She administered too rapidly causing pts pulse ox and respirations to drop. She admitted that she had never administered this drug and didn’t know how long or slow it needed to be given over

Violations of NPA will subject Nurses to Investigation by the BNE

Boards actions are administrative in natureLawsuits against Nurses are deemed civil in natureAt the board level, violations will prompt the BNE to

institute the investigation process which involves the following steps: Complaint filed Nurse informed of allegations in writing and asked

to respond Case will be reviewed and either dismissed or

informal conference may be requested After conf, case may be dismissed or discipline

recommended

Who is responsible for reporting to the BNE

Consumers Health care providers other than RN’s Attorneys Health care entities

Who is Required to Report Complaints to the BNE

RNs have a duty to report Peer Review Committees Health Care entities Professional Associations and Organizations State Agencies Professional Liability Insurers Prosecuting Attorney for Criminal convictions

Harsh Realities

Know your states NPA READ, READ, READ!

The NPA can be your best friend or your worst enemy

The NPA will be what attorneys will be looking to if you are ever named in a civil lawsuit

Your license is a property interest that the board can issue and also strip away

Harsh Realities Cont.

Aside from disciplinary measures from the BNE, nurses can be held criminally or civilly liable for their actions. As such they can and are being sued in court

Civil Liability results when a nurse failed to act or acted, but in a negligent manner

Criminal Liability arises when a nurse commits a crime against the state such as murder, assault, battery, theft, or DWI

Each type of liability can lead to the other

Civil Liability

Of the various areas of civil law, the area which impacts nurses most is tort law

Tort defined: a civil wrong committed against another individual

Torts can be intentional or unintentional Ex of intentional torts: false

imprisonment, invasion of privacy, assault, battery, slander

Ex of unintentional tort: negligence/malpractice

Civil Liability Cont.

Negligence: failure to act as a reasonably prudent nurse would have acted in the same or similar circumstances.

Gross Negligence: a nurses intentional failure to perform a duty and recklessly disregarded such duty

Nursing Malpractice is a subpart of negligence and can also involve a nurse’s failure to protect a patient from risk or harm or when the nurse fails to meet the standard of professional nursing practice

Malpractice Claims Against Nurses

The ANA has reported that nursing malpractice awards have totaled about $145,000

A few have reached the million dollar mark! In order for a plaintiff to be successful in a

malpractice suit, he or she must prove 4 essential components, otherwise the claim will dismissed.

4 Components of Negligence

Duty

Breach of Duty

Causation

Damages

Parties Involved in the Lawsuit Process

Plaintiff (s): person or persons initiating lawsuit Defendant(s): person or persons against whom

the lawsuit is TARGETING Witnesses: anyone closely or remotely involved

with the case Experts: witnesses utilized in lawsuits to rebut or

offer specific testimony Judge: person who oversees the trial process Juries: panel of individuals who decide the fate of

the Defendant(s)

Timeline for Filing a Lawsuit

Statute of Limitations: is the time frame for filing a lawsuit. Texas has a 2 year SOL. Typically, lawsuits brought after the 2 year period will be forever barred.

Exceptions: Fraudulent Concealment Discovery Rule Minors

Plaintiff must file Notice of Healthcare Liability in accordance with Chapter 74 of the Tex. Civ. Prac. & Remedies Code.

Anatomy of a Malpractice Suit

Most cases settle before ever going to trial Those that don’t settle will proceed to trial The trial process involves a series of events Voir Dire Opening Statements Presentation of Plaintiff’s Case Presentation of Defendant’s Case Closing and Deliberations

Proceedings Cont.

Once a lawsuit is initiated, the discovery process will take place and includes: Depositions Interrogatories Requests for Production, Interrogatories,

Requests for Disclosure Mediation Conferences

Remember

• Negligence can be based in the fact of omission and / or co-mission.

• Omission because we forgot to do something or we simply did not do something. We omitted it!

• Co-mission because we did something we should not have done, we did it late causing a delay in care or we did it wrong.

WE ARE ALL PROBABLY LUCKY TO BE BREATHING (LTBB)

• But we would never chart this, document this for our patient’s.

• Has it happened?

• Yes it has happened and then it was a mystery to unravel what LTBB actually meant.

• Would you as a nurse want to explain in court to a jury that you charted LTBB and then have to tell a jury/judge what LTBB means?

• As cited in an AJN article, there are many ‘gaps’ in clinical documentation with patient’s responses, outcomes and actions often not included as current nursing documentation.

• As the article noted documentation must also include evidence of assessment and patient progress.

• Despite the trend to streamline clinical records to improve compliance with nursing documentation, there is a real concern that nurses are not reflecting the holistic nature of their practice and work.

Example

• The patient was complaining of pain on a scale of 4 out of 10 using the pain scale.

– What did you do?

• You gave pain medication as ordered.

– But then what?

• You must reassess the patient within let’s say 1 hour to see if their pain has improved. Right?

• If you do not reassess how do you know the intervention was helpful to the patient?

• Perhaps you need to notify the physician for additional orders if the pain medication was not effective.

• What if the patient sues the nurse and the hospital because he/she claims to have been in unbearable pain for 2 days.

• How do you know if this is true or not?• Is this a legitimate claim?• If you did not record patient’s response to the

intervention of giving the pain medication but you are consistently giving pain medications without further intervention on behalf of the patient then you look guilty in the fact that you did not advocate for the patient thus you dropped the standard of care. Right?

Documentation is often seen as taking time away from nursing care rather than being a part of nursing practice and care.

So, What’s the Problem????So, What’s the Problem????

Use the nursing process to document:• The words you choose in charting today could

come back to haunt you tomorrow and many tomorrows thereafter up to 7 years depending on the statute used.

Nursing Process Steps:

• Assessment.  This is the first step of the nursing process.  It involves the systematic and continuous collection, validation (evaluation) and selection of data. 

• Nursing Diagnosis.  From the assessment of functional health patterns human response patterns are identified and classified according to statements of actual, high risk and possible problems, and wellness diagnoses

• Planning.  Specification of client goals to promote health and/or prevent, reduce, or resolve the problems that are identified in the nursing diagnoses, and related nursing interventions. 

• Intervention.  Implementing the plan of care • Evaluation.  Measures the extent to which the

patient/client has achieved the goals specified in the plan of care, and identifies the factors that positively or negatively influenced goal achievement. 

Document, document and document should be the mantra around all care activities.

• Moreover, documentation needs to go beyond what was actually performed, to include the thoughts, statements and intentions of both the provider and the care recipient.

• Documentation should reflect this shared effort.

Document Everything Pertinent

Moreover, documentation needs to go beyond what was actually performed, to include the thoughts, statements and intentions of both the provider and the care recipient.

• Documentation should reflect this shared effort.

How to protect your license

• Accurate Documentation • Factual Documentation • Complete Documentation • Abbreviations

(use only approved)• Unsolved Mysteries ( avoid them) do not keep the

reader guessing!• Criticism

(avoid it)• Corrections and Late Entries ( Be specific)• Confidentiality

Coordination of Care (when did you call the physician and why/ for what reason?)

Case Study

• The plaintiff’s decedent, age seventy-eight, was a resident at the defendant’s nursing home. She complained of dizziness and nausea in December 2004. No vital signs or blood count were taken.

• The next day, the decedent was found unconscious with blood on her sheets, pillows and adult diaper.

• The plaintiff claimed that the blood-soaked articles were removed and the decedent was cleaned up before her family was contacted.

• The decedent’s daughter claimed that she was told that her mother had died of a heart attack.

• The chart entry on the death only noted that the decedent was found without respiration and no mention was made of her bloody condition.

What did the autopsy tell?

• An autopsy found that the death was due to a gastrointestinal hemorrhage and that she had probably been bleeding internally for several days.

• The plaintiff claimed that several entries in the decedent’s chart were false, including a notation that the decedent had received an insulin shot an hour before her death, and late entries concerning bleeding which were made by nurses who were not even on duty.

What do you think happened in this case?

• According to a published account a jury returned a $54 million verdict, which included $4 million in compensatory damages and $50 million in punitive damages.

• Eighty percent of fault was assessed against the facility and twenty percent was assessed against two nurses.

• With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298

Another Case Study

• The plaintiff’s decedent, age fifty-nine, underwent an elective outpatient knee surgery in March 2003 at the defendant hospital.

• The surgery was reportedly uneventful. • However, while in the post-anesthesia care unit

her blood pressure began to steadily increase. She soon stopped breathing.

• The defendant, the nurse in the unit, administered Narcan to the patient.

Snap shot of the case:

• The blood pressure spiked to 287/169. The plaintiff claimed that this caused the capillaries in her brain to leak fluid and her brain to swell against her skull.

• A call for a physician was made eleven minutes after she stopped breathing and a physician responded three minutes later.

• Medication was administered to counteract the Narcan (????).

• The decedent had suffered brain damage and was in a permanent vegetative state.

• Life support was removed two days later. • The woman died four days after the surgery.

What do you think happened here?

• Where was the standard of care dropped?

• What is the issue in the delayed call to the physician?

• Do you see negligence?

• How could this have been prevented?

• Would you have an issue with this type of documentation?

What did they all have to say?

• The plaintiffs alleged negligence by the nurse in failing to call a code or to immediately alert a physician for eleven minutes, during which brain injury resulted.

• The defendants argued that the nurse had immediately called for a physician, but received no response.

• The nurse claimed that she had simply followed the orders of the certified nurse anesthetist in the unit when a physician did not immediately appear after her first call. The defendants also contended that the decedent had actually died due to an extremely rare tumor in her adrenal glands, which caused her blood pressure to spike.

• An autopsy did not reveal any tumor.

What do you think happened?

• Did the nurse simply follow orders?• Did the nurse delay care?• Did the nurse anesthetist fail in her duties?• Did the nurse fail in her duties?• Did the physician/surgeon drop the ball on this

one?• There was minimal to no documentation to

support anyone’s claims that they did their job.• What is your conclusion?

Results

• According to a report, a $675,000 verdict was returned against the nurse.

• $1 million against the facility.• $1 million against the Nurse Anesthetist• $2 million against the facility.

Case Study

• The plaintiff’s decedent underwent neck surgery in January 2003 which was performed at a Medical Center.

• The decedent’s family claimed that he was fine in the recovery room.

• After transfer to his room the decedent began experiencing respiratory distress.

• His family claimed that the problems started an hour earlier than the hospital staff maintained that the problems began. The decedent went into respiratory arrest and a code was called.

• He was eventually placed on life support and he died at the hospital when life support was removed about ten days later.

What happened?

• It is a mystery because there are no documentation notes to support what happened after the transfer until the patient arrested.

• The notes were created after the fact.• The assessment was not done initially or

documented initially.

• Who dropped the ball on this one?

• Tell me your thoughts?

The allegations:

• The plaintiffs alleged negligence by the hospital staff in failing to properly monitor the decedent after his arrival in the room.

• The plaintiffs also claimed that the nurses failed to notify the attending physician of problems in a timely manner.

• Note that the vital signs were added in as a late entry into the documentation for this patient.

• What do you think that problem was in this scenario?

Defendants claims:

• The defendants generally denied any negligence and claimed that preexisting conditions and superseding events outside the hospital’s control caused the death.

End Result:

• According to a published account a $2,225,000 verdict was returned and this became a licensing issue for the nurses involved.

Bottom Line

• Due to financial pressures in healthcare, nursing services have a mandate of efficiency and measurability.

• Why do you think this has happened?

• The implementation of standardized languages, nursing diagnoses, and outcomes allows for increased practicality and efficiency of nursing data management.

• The definition of a nursing diagnosis is “a clinical judgment about an individual, a family or a community’s response to actual and potential health problems/ life processes.”

What does all of this mean?

• Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

• Nursing interventions are regarded as nursing treatment which are based on clinical judgment and knowledge and which are carried out by nurses in order to improve patient outcomes.

• Nursing Outcomes are described as changes in the patient’s health as a result of nursing interventions.

• Defining aspects of nursing outcomes are regarded as measurable or observable results across a time period.

• One of the measures of quality for nursing outcomes is to link them with nursing diagnoses and intervention and evaluate them in that context (National Academy Press,1999).

The computer age

• Electronic health care records have made a major difference in the lives of the practicing nursing professional.

• We now have built in screens with prompts to let us know that a specific area of documentation is needed.

• The problem is that we as nurses learn to circumvent the system.

• When we do this we are more prone to mistakes in our documentation.

Electronic charting

• “EHR charting is more structured; you’re forced to choose from various options in multiple lists (drop down lists). You have to change your thinking about charting.”

• That doesn’t lessen your responsibility to document thoroughly and accurately, so you must understand how the system works and use it properly.

Always remember:

• When properly implemented, information technology can

• simplify information retrieval, reduce medical errors, and

• improve communication, among other pluses. • But information• technology doesn’t eliminate the need for

professional• judgment.

Keep in Mind!

• “People are not infallible.

• Neither are computers—

• But we tend to think they are,” said Melanie Balestra, JD, MN, NP, a California-based attorney.

Some potential pitfalls of EHRs

• Compared with paper records, an EHR can store more information for longer periods.

• Also, an EHR is accessible concurrently from many workstations and can provide medical alerts and reminders.

• Despite these and other advantages, an EHR can make one of your key responsibilities—documenting patient care—more difficult.

• “Traditional paper charting is free-form and leaves more room for errors.

• You have to change your thinking about charting.”

• That doesn’t lessen your responsibility to document

thoroughly and accurately, so you must understand how the system works and use it properly.

• “For instance, what if you enter something into the wrong patient’s chart?”

• What do you do? What do you do on paper and what do you do in the electronic record?

Paper vs EHR

• On paper you’d line through the entry once and initial or sign it, but you can’t do that in an EHR.

• And, if you are able to make a correction, will the system still save the mistake?”

• What is our process at Del Sol?

• If you record the information in two different places

and make a mistake in one of them, you introduce a conflict.

• Whether you can correct charting mistakes easily or at all may depend on the safeguards built into the system.

What records are legally valid?

• Remember that reports or other documents transmitted via “low-tech” e-mail or fax can be just as legally valid as paper originals or records stored in an EHR.

• “They’ll generally hold up in court as long as automatic date stamps or other systems are in place to prove they’re authentic and weren’t altered.”

• Also any documents that you mention in your nursing notes may be discoverable if an attorney picks up on this information.

• A patient’s medical record can be subpoenaed in court and the information that has not been recorded could prove as useful as the documented record.

• With all patient-related documents, whether paper or electronic, taking appropriate security measures to protect privacy remains a top priority!!!!!!

• To comply with the regulations of the Health

Insurance Portability and Accountability Act (HIPAA), you must Do everything possible to prevent unauthorized people from viewing patients’ health information.

How do you document in your notes?

You have a 29 year old female admitted to your medical surgical unit at 0900 hours.

The primary medical diagnosis is anemia of unknown origin.

Vital signs T 98.1, P72 R 24 B/P 120/60 initially

The patient is pale, warm and dry. 0945 She is crying because she is frightened and does not want to be in the hospital. One hour into the shift you note the patient is in the bathroom vomiting, you smell blood and proceed to look at the toilet contents. You see bright red blood in a moderate amount. The time is 10 am. 0930 Your head to toe assessment at 0900 hours is unremarkable.

Document this: Use the nursing process!

References

Kohn LT, Corrigan JM and Donaldson MS, Editors. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press. 1999.

Centers for Disease Control and Prevention (National Center for health Statistics) Deaths: Final Data for 1997. National Vital Statistics Reports: 47:19) 27.

Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. JAMA. 277:307-311, 1997.

Hanka, R. (1997). Information overload and 'just-in-time' knowledge. Center for Clinical Informatics. Retrieved on July 7, 2003 from http://www.medinfo.cam.ac.uk/miu/papers/hanka/mic97/just_in_time.html

Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298

Ash JS, Berg M, Coiera E, et al. Some unintendedconsequences of information technology in healthcare: the nature of patient care information system relatederrors. J Am Med Inform Assoc. 2004; 11,

Test Taking for this course:

• You will be given 3 case scenarios using a performance based data system and are required to document on each scenario as if you were the nurse and the person in the scenario was your patient.

• Please document as you would if you were the primary nurse for this patient.

• Use the nursing process and remember we must always document for a jury! Just in case…..

NPA

• But, there is more to this story

• Here is some of the stuff you haven’t heard yet

NPA

NPA

• Action taken against nurses licensure can take many forms, but a couple of the big issues are failure to document, failure to inform, failure to rescue.

• Chart Check, Medication wastage