Documentation, Litigation, Tarnation 

1. Documentation, Litigation, Tarnation Camille Ciarniello, BSN, LLB Director, Risk Management & Patient Safety Providence Health Care

2.  Tarnation A colloquial euphemism for damnation, primarily used in the southeastern United States, part of the expression "What in tarnation?" used to indicate disbelief.

3. What patients really want… • Don’t hurt me • Help me • Be nice to me Dr. Donald Berwick

4. Provide Patient Centred Care • No harm • Evidence based care reliably provided • Ask the patient what they want and need • Help shape the patient’s expectation • Tailor care and service to individual patient’s desires, wants and needs

5. Ares v. Venner (1970) SCC There is a circumstantial guarantee of trustworthiness for the records are made and relied upon in affairs of life and death. Moreover amidst the day-to-day details of scores of hospital cases, the physicians and nurses can ordinarily recall from actual memory few or none of the specific data entered

6. Ares v. Venner (1970) SCC Hospital records, including nurses’ notes, made contemporaneously by someone having a personal knowledge of the matters being recorded and under a duty to make the entry should be received in evidence as prima facie proof of the facts stated therein.

7. Ares v. Venner (1970) SCC Nurse’s notes can be admitted as evidence at trial for the proof of their contents. This is considered a “business exception to the hearsay rule of evidence”: • Authors are taught principles of documentation • Documentation is part of the “business” of health care • Documentation is done close to the time care is provided

8. Gemoto v. Alberta Children’s Hospital • “…the standard of care owed is established both by what was known or was reasonably knowable about Chad at the time. The standard of care is not and never has been measured only by looking at the actual thoughts, perceptions or actions of a particular defendant, limited to what they in fact knew, saw or did”.

9. Gemoto v. Alberta Children’s Hospital • A second principle at play here is the numerous deficiencies in the Hospital chart concerning Chad's monitoring, assessment, care and treatment. The Hospital has admitted substandard charting by the nurses.

10. Gemoto v. Alberta Children’s Hospital • The Defendants have, contrary to their duty to document, deprived the Plaintiffs and this Court of useful information. If there had been diligent record keeping the Court would have had data on Chad's condition throughout the afternoon. An analysis of what occurred could have proceeded by reviewing customary records along a documented time line and it would have been possible to take an accurate snap shot of certain moments in time, without reference to what occurred in a later frame.

11. Charting basics

12. Charting basics • Right chart, legible handwriting, contemporaneous with care • Document objective evidence that demonstrates critical thinking • Use late entries appropriately • Document each call to a physician • Use correct spelling and grammar - spelling errors and poor grammar reflect on credibility

13. What does this mean? “Patient easily aroused.”

14. How could this be interpreted? Definition of aroused: Excited, tense, sexy, passionate, agitated

15. Charting habits to avoid • Charting symptoms and not charting any intervention • Using unaccepted abbreviations • Charting subjectively • “Lump” charting! • Charting someone else’s observations • Charting in advance

16. Charting habits to avoid • Charting gossip and blame, administrative problems or judgments • Using terms incorrectly

17. Why is consent necessary? • Respect for autonomy • An unjustified application of force to another person constitutes a “battery” • Mandated by legislation • A communications process and patient safety tool

18. Informed Consent

19. Who should obtain consent? • Ultimate responsibility resides with the accountable caregiver • A caregiver may delegate elements of the consent process • Nurses do not assume the physician’s obligation to inform, although they play a vital role in patient teaching

20. Elements of consent Consent must be: • Given voluntarily • Given by a patient with capacity • Referable both to the treatment and to the person who is to administer the treatment; and • Given by a patient who is informed

21. Elements of “Informed” Nurses provide clients and substitute decision-makers with the information that a reasonable person would require in order to make a decision about proposed health care. This includes information about: • The condition for which the health care is proposed. • The nature of the proposed health care. • The risks and benefits of the proposed health care. • Alternatives to the proposed health care. The information is sufficient, specific and evidence-based. CRNBC Practice Standard

22. Elements of “Informed” • The patient must have been given an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available. The information must be such as will allow the patient to reach an informed decision. In situations where the patient is not mentally capable, the discussion must take place with the substitute decision maker. CMPA Consent Guide for Physicians

23. What the Doctor Said We need to do a colonoscopy to determine if there is a cancerous growth in your lower bowel. The procedure involves a local anaesthetic. I pass a long tube up the rectum to take a look. There are some risks, including perforation of the bowel, and some pain. You should be fine a day after the procedure although there are no guarantees in medicine.

24. What the Patient Heard …. CANCER…. PAIN………. YOU SHOULD BE FINE, I GUARANTEE IT.

25. Consent is a process – not just a form – but both are important

26. Disclosure Nursing Values and Ethical Responsibilities 5. Nurses admit mistakes and take all necessary actions to prevent or minimize harm arising from an adverse event. They work with others to reduce the potential for future risks and preventable harms. CNA Code of Ethics for Registered Nurses