Documentation: the way to protect yourself from falling in malpractice

1. Documentation:the way to protect yourself from falling in malpractice By: Mr. Nahar Mohd Al Reshidi Director of Nursing King Khalid Hospital- Hail Important topic for Oncology patients and Nurses Immunosuppressed patients are at a high risk for getting infections, not being able to fight the micro-organisms, becoming Febrile/Neutropenic and if not treated early and properly suffering septic shock (Life threatening emergency) Important topic for Oncology patients and Nurses Immunosuppressed patients are at a high risk for getting infections, not being able to fight the micro-organisms, becoming Febrile/Neutropenic and if not treated early and properly suffering septic shock (Life threatening emergency)

2. OUTLINE: What is Documentation Why is Documentation Significance of Documentation for Legal Purpose FACT mnemonic Elements of Documentation Legal Aspects of Charting Who�s & Why�s of Documentation

3. Introduction In today�s healthcare field the nurse not only has a professional responsibility, but is also held responsible to document patient data that accurately reflects nursing assessment, plan, intervention and evaluation of the patient�s condition.

4. What is Nursing Documentation? Any written or electronically generated information about a client that describes the care or service provided to that client.

5. Through documentation � nurses communicate their observations, decisions, actions and outcomes of these actions for clients.

6. Documentation is An accurate account of what occurred and when it occurred. Nurses may document information pertaining to individual clients or groups of clients.

7. WHY WE NEED DOCUMENTATION

8. To facilitate communication � nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. increases the likelihood that the client will receive consistent and informed care or service accurate documentation decreases the potential for miscommunication and errors.

9. To meet professional and legal standards Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. be used as evidence in legal proceedings such as lawsuits, coroners� inquests, and disciplinary hearings through professional regulatory bodies. In a court of law, the client�s health record serves as the legal record of the care or service provided.

10. To promote good nursing care � Nurses are encouraged to assess client progress and determine which interventions are effective and not, identify and document changes to the plan of care as needed. A valuable source of data for making decisions about funding and resource management as well as facilitating nursing research, all of which have the potential to improve the quality of nursing practice and client care. Nurses can use outcome information from a critical incident to reflect on their practice and make needed changes based on evidence

11. Documentation is significant for legal purposes

12. Legal Protection � Nursing documentation is often the starting point in many malpractice cases.  Malpractice is a type of negligence in, which the professional under a duty to act, fails to follow generally accepted professional standards, and that breach of duty is the proximate cause of injury to a plaintiff who suffers harm.

13. Accurate nursing documentation can either deter a plaintiff from filing a lawsuit or provide the leverage that is required to initiate one. In reviewing nursing documentation it is critical to show that the set standard of care was met.

14. Jurors and attorneys view what is written in the patient�s record as the best evidence of what really occurred. For these reasons it is extremely important that nursing documentation is timely, accurate and complete.

15. F A C T If care is not documented, courts assume it was not rendered. When documenting care on the patient's chart, use the FACT mnemonic: Factual, Accurate, Complete, and Timely

16. Documentation should include the following: Direct quotations from the patient, family or visitors; Data that has been gathered; Actions taken; Individuals notified about concerns and issues and, Evaluation of Actions

17. Legal Aspects of charting should include: First, making sure you have the correct chart (MOST IMPORTANT PRIORITY) Writing neatly and legibly Conveying significant details Signing and dating every entry

18. Legal Aspects of charting should include: (Cont.) Using proper spelling, grammar and appropriate medical phrases Using authorized abbreviations only Assuring patient�s name is on every page A single line through entry errors and your initials (no erasing or �white out�)

19. Nursing documentation and progress notes that are filled with misspelled words and poor grammar create a negative impression.! Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless.

20. Many cases brought to litigation in the malpractice arena hinge on poor communication between healthcare providers of the same and different disciplines.

21. The first thing a nurse should be aware of is who will be reading the document and why, including: The health care team The scribe The lawyers and experts The judge and jury

22. 1. The healthcare team Other members of the healthcare team will be reading the document, so it's important to provide information about the patient that's accurate and complete, reflecting a picture of the patient while under the watch of each nurse.

23. The overall goal of nursing documentation is to create an illustrated timeline for the care of the patient. This means that each entry by each member of the healthcare team must be integrated.

24. Documentation uses words to paint a picture of the patient at specific time intervals and assists subsequent and interdisciplinary caretakers in determining if and to what extent changes have occurred in the patient's status.

25. Therefore, documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care.

26. 2. The scribe The nurse is also documenting for her own purposes.

27. Documentation that's complete and accurate can also serve as a memory refresher when details are unclear or forgotten

28. Documentation must be accurate, clear, concise, complete, and timely. Speed is of the essence when working in healthcare, but accuracy and completeness are imperative when documenting. Do not let the patient�s health be compromised by worrying about the speed; make sure it gets done right the first time.

29. Lawsuits can typically be brought within 2 years of the date of the event resulting in a claim. It may be an additional 2 years by the time the formalities of litigation take place.

30. That's why complete documentation at the time of patient care is the only accurate way for the nurse to remember the details of the particular patient at the time surrounding the event

31. 3. lawyers and experts The nurse's documentation is read by lawyers and experts when a lawsuit ensues. Every microscopic detail of the medical record is examined. They're looking to see what went wrong and what could have been done better

32. The goal is To provide complete and accurate documentation about patient care that was rendered according to acceptable standards of nursing care.

33. 4. The judge and jury. The nurse's documentation may also be read by non-nursing or non-medical jurors deciding a case.

34. These cases are already seen as complex and confusing to someone that isn't familiar with the healthcare world. This is another reason why it's important to be concise and clear with all entries.

35. Legal and ethical issues often become entwined in health care settings, and nurses must be knowledgeable in both

36. Nurses� notes are recognized as documentary evidence.

37. Make sure the right information gets documented and that documentation is done correctly.

38. References: AJN, American Journal of Nursing September 2003� Volume 103�Number 9 Richard, N. (1995). Charting: A professional responsibility - Part IV. Info Nursing, 26(2), 7-8. Website - www.crnbc.ca