Defensive Documentation: Avoiding Malpractice NSNA Conference April Lori Klingman MSN, RN

Transcription

1 Defensive Documentation: Avoiding Malpractice NSNA Conference April 2010 Lori Klingman MSN, RN

2 Legal Documentation Communication problems lead to malpractice Inadequate documentation 2

3 Document Your nursing care is communicated to others of the health care team through the medical record Medical records are legal documents What you write reflects the quality of your care 3

4 Avoid Malpractice Good charting is your best legal defense! Careless, inaccurate, or incomplete charting can hurt you in a court of law Paint a picture of the patient so that others who read the chart will know what you saw and did 4

5 Chart Promptly Charting promptly encourages fresh, detailed notes If you wait until the end of the shift, you could forget to include important information 5

6 Keep it Neat You cannot communicate properly if others can t read your writing in the chart Illegible handwriting wastes time and could lead to patient injury Print if your handwriting is hard to read 6

7 Write in Ink Medical records are permanent documents Use dark ink to ensure proper photocopying Use water resistant ink so no smudges occur 7

8 Check Spelling and Grammar Misspelled words and poor grammar make an unprofessional impression Use a pocket dictionary Keep a list of commonly misspelled words and medication names 8

9 Use Only Approved Abbreviations Unfamiliar or seldom-used abbreviations can confuse other caregivers and lead to potential patient injuries Keep your hospital s list of abbreviations handy Familiarize yourself with them Use them consistently 9

10 Write Clearly and Distinctly Make sure each sentence has a subject Avoid words like appears or apparently These make you sound unsure of your observations 10

11 Specify Times Chart exact times, especially when you document significant patient events Change in condition Nursing actions Avoid entries such as This implies inattention to the patient 11

12 Chart in Chronological Order Patient improvement or deterioration is easier to spot when events are charted in the order they occur You may omit important clues if you wait until the end of your shift If you must delay, keep a list of notes to expand upon once you can chart 12

13 Be Accurate, Objective, Complete Document what you see hear and do Opinions and assumptions do not belong in the chart Use quotes when documenting what the patient said Relate all aspects of patient care to the nursing process 13

14 Sign Each Entry After recording information sign your first initial and last name with your professional status 14

15 Correct Errors Properly If you make a mistake, draw a line through the incorrect info Add correct info and an explanation on the next available line Initial the changes you made Never erase or scribble over an incorrect entry It could look like a cover-up if in a court of law 15

16 A Job Well Done What you document tells others about the care you give Proper documentation creates a lasting impression of a job well done 16

17 Legally Safe Charting Rules Check that you have the correct medical record before documenting Your documentation should reflect the nursing process and your professional capabilities Chart med given, route, and pt s response 17

18 Legally Safe Charting Rules Cont. Record each phone call to the HCP, including the exact time, message and response Chart a patient s refusal of medication or treatment Report this to the HCP 18

19 Legally Safe Charting Rules Cont. Chart patient care at the time you provide it Use late entry if you remember an important point after you complete documentation Document often enough to tell the whole story 19

20 Computer Documentation Never let another person use your password Always log off computer Never leave an open terminal Any falsification, tampering, or excessive dispensing of medications can be tracked back to you Select a password instead of using an assigned one 20

21 Computer Documentation Avoid passwords that are easily associated with you Do not write down your password Choose a password that you easily remember Change your password frequently Enter your password when no one is watching 21

22 Computer Documentation If you suspect someone is using your password, change it immediately and notify Information Systems (keep a copy of your report) NEVER let another person work on a terminal that you are logged into Remember HIPPA 22

23 Don ts 23 Don t chart a symptom without charting what you did about it (remember the nursing process) Don t alter a patient s record This is a criminal offense! Don t use shorthand or unapproved abbreviations Don t write imprecise descriptions such as a large amount

24 Don ts Cont. Don t give excuses, such as medication not given because it was not available Don t chart what someone else said, heard, felt, or smelled unless the information is critical In that case, use quotations and attribute the remarks to who said them Don t chart care ahead of time This is considered fraud 24

25 Guidelines for Documentation & Reporting Factual Accurate Complete Current Organized 25

26 Standards Hospitals are required to follow Department of Health standards Consequently, all in-patients must have: Physical assess Psychosocial assess Environmental assess Self-care assess Client education Discharge planning 26

27 Telephone Orders 27 Physician must prescribe therapy by phone to ONLY an RN Listen Write Repeat EX. 10/24/20 11:00 pm Give Regular insulin 10 Units STAT V/O or T/O Dr. Reaback/ L. Klingman RN

28 Incident Reports Event not consistent with routine operations of unit Examples Falls Needle stick injuries Medication errors Omission of ordered therapies Circumstances that lead to injury 28

29 Report Forms Whoever witnesses incident writes the report Complete report even if no injury apparent Sent to hospital dept. for review: Risk Management Legal department Employee health 29

30 What to Include Witness writes report Be concise and objective Describe person s condition when found Report measures taken by staff or HCP Discussion of incident on your report should have no more than what is documented in the chart 30

31 What to Include Do not explain cause or place blame Submit report same day of occurrence Do NOT photocopy- can be subpoenaed in court Hospital has 24 hours to report a sentinel event to the Department of Health 31

32 Inaccurate Note Client fell OOB, c/o pain in L hip. Noted external rotation & shortening of L leg. Dr. Smith notified. 32

33 Accurate Note 10/10/2010 2:45 AM: Client found on floor, c/o pain L hip. Noted external rotation & shortening of L leg. Lifted back to bed with assist of three. Vs: BP 142/88; P= 90, R= 22. Side rails up, call light within reach, instructed client to remain in bed. Dr. Smith notified, portable L hip x-ray ordered STAT. 33

34 Charting Errors Patient has chest pain if she lies on her left side for a year The patient has no past history of suicides The patient was in good health until his airplane ran out of gas and crashed She is numb from her toes down She has had no chills, but her husband states she was very hot in bed last night 34

35 What Leads to Litigation? 35 Medication error is most common mistake Not questioning an order Decimal point errors Omission of medication Medication given was not documented immediately and another person gives the med again As a supervisor, you can be held responsible for subordinate s actions

36 Terminology Plaintiff- person who brings a lawsuit Patient, spouse, children Bears the burden of proof Defendant- party being sued Codefendants- hospital, physician, and nurse Complaint- filed in court by attorneys on behalf of the plaintiff 36

37 Actions Civil Action- plaintiff (patient) sues defendant (nurse/hospital) for damages Criminal Action- person charged with a crime Prosecuted in state or federal courts Disciplinary Action- carried out by the State Board of Nursing Nursing license can be suspended or revoked 37

38 Ways to Avoid Being Sued Routinely broaden your knowledge and skills Keep abreast of medical changes by reading medical books, pertinent journals for the area in which you work, attend continuing education programs, go back to school 38

39 Ways to Avoid Being Sued Follow the Nurse Practice Act Practice within its scope Periodically review your job description Practice within its scope Be aware of Policy and Procedural changes Never go astray from the policies 39

40 Ways to Avoid Being Sued Never give meds with which you are not familiar Check reference books Call the ordering HCP when an order is vague, then pursue the chain of command 40

41 Ways to Avoid Being Sued People are less likely to sue if they like you Always use good bedside manners Treat all patients and families with respect Always act in a professional manner 41

42 Critical Thinking Exercise When documenting by computer, are you held liable the same as when working with a manual system? 42

43 Critical Thinking Exercise You work in IMC and your manager has decided to use nursing assistants to apply dressings, perform suctioning, and draw blood. The assistants are not licensed to perform these tasks nor document in the patient s chart. You tell the manager you cannot chart for someone else. What should you do? 43

44 The PBB Case An elderly patient developed decubitus ulcers. The family c/o improper care. The pt. died of probable natural causes. After her death a suit was filed by her family. During discovery, the letters PBB were found under the pt s prognosis. Do you know what PBB means as a prognosis? 44

45 The UKD Case 45 An obstetrician delivered a baby via C- section, felt something was abnormal about the child s appearance even though the baby had a normal Apgar score. The M.D. wrote UKD as his impression. The child was diagnosed with cerebral palsy and the parents sued alleging this resulted from hypoxia. The medical record established a strong defense for the M.D. Who knows what UKD means?

46 References Brooke, P. (2009). Hiring an attorney. Look for expertise. Nursing :39(8):9. Brooke, P. (2009). Statute of limitations- time for a lawsuit may never run out. Nursing :39(12):10. Brous, E. (2009). Documentation and litigation. RN. 2009:72(2)

47 References Cohen, M. (2009). Handwriting order- trouble 4 U. Nursing :39(6):11. Cohen, M. (2009). Apnea Risks- hold the hydromor-phone. Nursing :39(10):19. Cohen, M. (2009). Provera or Prozac? Problem handwriting. Nursing :39(11):15. 47

48 References 48 Grant, B. (2009). Engaging the patient in handoff communication at the bedside. Nursing :39(8): Hall, D. (2010). Med reconciliation do the right thing. Nursing Management. 2010:41(2) White, K. (2009). Get the facts about the new CMS payment system. Nursing Made Incredible Easy. 2009:7(1):24-30.

49 49 The End