DOCUMENTATIONAs a Loss Prevention

Technique

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Today’s Objective

» Increase awareness of documentation risks, specifically targeting exposure to negligence and malpractice claims.

» Enhance the quality of documentation by expanding awareness in order to provide quality patient care and avoid malpractice incidents.

» To address the documentation steps in order to implement, and thus help protect your patient from harm and minimize your liability exposure.

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Legal Perspective on Documentation

• Not documented, not done.

• Poorly documented, poorly done.

• Incorrectly documented, fraudulent.

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Quality Documentation is Quality Care

• Structured writing typically inspires structured performance.

• Document the Nursing Process:

Assessment

Diagnosis

Planning

Implementation

Evaluation

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You are what you document

A well-documented patient care record: Protects your patient Demonstrates to the board of nursing that

you are a competent nurse. Minimizes the potential of being named

as a defendant in a lawsuit. Minimizes the potential of a court

appearance if you ARE named in a suit. Help you win if you go to court.

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The Patient Care Record is a Legal Document.

• Under state laws, the patient care record is the property of the health care provider.

• Patient is entitled to a copy of the record under the laws of most states.

• The record must reflect accurate and contemporaneous information.

• The patient care record documents the care provided.

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Basis for Reimbursement

Your documentation may

influence how you and your

employer are reimbursed for

services rendered and

minimize financial loss.

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Considerations for Quality Documentation

Contemporaneous documentation

Accurate documentation

Fraudulent documentation

Inappropriate documentation

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Documentation as a Loss Prevention Technique

• Documentation Dos and Don’ts:

• 10 Risk Management Strategies

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Risk Management Strategy 1

Do not erase.

Do not use “white out”.

Do not cross out an error with more than one line.

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Risk Management Strategy 2

Record only the facts.Document only observed

behavior.Document healthcare services

rendered.

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Risk Management Strategy 3

Do not write critical comments.

Do not document your opinions.

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Risk Management Strategy 4

Begin each entry with the date and time and end each entry with signature and

title.

Example:

(03/31/09 - 7:50AM - Jane Doe, BCCNS)

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Risk Management Strategy 5

Do not leave blank spaces.

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Risk Management Strategy 6

Record all entries legibly and in ink.

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Risk Management Strategy 7

Avoid generalized phrases such as "bed soaked" or "a large

amount."

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Risk Management Strategy 8

If an order is questioned, document that clarification was sought and discussed.

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Risk Management Strategy 9

Document only your own observations and patient

services rendered.

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Risk Management Strategy 10

Do not permit any visiting relative or other third-party access to the patient care

record.

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Communication Challenges

Attributes:» Factual» Accurate» Current» Confidential

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Reporting Challenges

Oral Report – Typically, conducted at change

of shift.

Documentation/Written Report – Completed during shift.

Nurses must communicate information about patients to other nurses and other health care workers.

Documentation Techniques

Strengths and Weaknesses

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Documentation Methods

• Charting by Exception

• FOCUS

• Narrative

• SOAP

• Electronic

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• Charting by Exception

Documentation Methods

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Documentation Methods

• FOCUS

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Documentation Methods

• Narrative

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Documentation Methods

• SOAP

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Documentation Methods

• SOAP (SOOOAAP)

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Documentation Methods

• Electronic

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Effective Risk Management Strategies

• Comply with Nurse Practice Act

• Practice Competent Nursing

• Comply with Policies and Procedures

• Follow Appropriate Incident Reporting

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Incident Reporting

Losses can be reduced by a

timely, prudent, and

compassionate response to an

incident!

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Learn Your Organization’s Guidelines

Examples of Reportable Incidents

• Patient falls

• Medication errors

• Equipment failure

• Complaint by patient, family, visitor

• Treatment-related injuries

• Missed/incorrect diagnosis

• Employee exposures

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BE ALERT! Report unusual occurrences

Document ONLY the facts

• Report immediately, i.e., within 24 hours.

• Do not speculate.

• Do not draw conclusions.

• Do not document impressions.

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QUALITY MONITORING

• Participate in investigations.

• Maintain confidentiality of all information.

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Open Charting

• Encourages patients to review their own patient care record

Promotes meticulous documentation by healthcare providers

Fosters patient inclusion in the healthcare delivery process

Requires significant timeMay raise patient queries

regarding the healthcare delivered

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Documentation Examples

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Documentation Bloopers

• “The patient refused an autopsy.”• “The patient has no previous

history of suicides.”• “Patient has left white blood cells

at another hospital.”• “On the second day, the knee was

better, and on the third day it disappeared.”

• “The patient has been depressed since she began seeing me in 1993.”

• “Discharge status: Alive but without permission.”

• “Healthy appearing decrepit 69-year old male, mentally alert but forgetful.”

• “Patient had waffles for breakfast and anorexia for lunch.”

• “She is numb from her toes down.”• “While in ER, she was examined,

x-rated, and sent home.”• “The skin was moist and dry.”• “Patient was alert and

unresponsive.”• “Rectal examination revealed a

normal size thyroid.”• “She stated that she had been

constipated for most of her life, until she got a divorce.”

• “Skin: somewhat pale but present.”• “Patient has two teenage children,

but no other abnormalities.”

THE END