Barbara Hansen, MS, RN, LNCC, CPHRM. Copyright 2015 by The Medical Resource Network, Inc.
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1 Barbara Hansen, MS, RN, LNCC, CPHRM Copyright 2015 by The Medical Resource Network, Inc.
2 I have no known conflicts of interest. The presentation presents only hypothetical situations. I am not a lawyer and am offering no legal advice. This presentation will be updated with current information.
3 1. Identify the four elements of professional negligence. 2. Discuss the role of nursing documentation in proving negligence. 3. Discuss the impact of the EMR on medicallegal cases. 4. Describe strategies to avoid documentation concerns.
4 Who are we?
5 Dr. Baker said to not over medicate Mr. Jones. To give him Ambien for sleep. I suggested temazepam as this is what Mr. Jones was taking at home. Dr. Baker said No, he d empty the pharmacy if you let him.
6 Duty to patient Breach of duty Reasonable standard Proximate cause Breach of duty caused injury May be more than one Prove monetary loss (damages)
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8 An immovable object that is unchangeable, except when smoothed by persistent waters.
9 Facts from Paper are not the same as Facts from People. The reliability of the people giving you the facts is as important as the facts themselves. - Harold S. Geneen
10 Delete Cut and paste Copy and paste
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14 EMR - Electronic Medical Record EHR - Electronic Health Record: Data is shared across providers & with patient
15 Institute of Medicine (IOM) for Patient Safety & Quality of Care Competencies in EMR documentation HIT Health Information Technology
16 Searchable Facilitates communication between providers Reports
17 Intensive training Copy/paste; carry forward Auto-population of data Number of steps to verify information Can hinder communication between providers
18 ID consult for UTI & multiple allergies Allergies listed: Penicillins, cephalosporins, sulfonamides Pt is GBS + - Plan is to give vancomycin & admit & consult ID No information about reactions to above allergies listed! Patient is asked she doesn t know, maybe happened when she was a baby? blogs.jwatch.org
19 Mother of patient is called, no answer, voice mail full Patient texts mother, mother responds pt got very sick with penicillin when a baby Mother recalls maybe had strep throat a couple of times but does not remember abx Peds care at local specialty group part of this healthcare system decision to access these records Can t access, so ticket to IT will it get resolved in time?
20 Call to peds practice, but after 5 p.m. Practitioner with the above peds group walks by Logs into EHR and looks at pt s age 13, treated with cephalexin no allergic reaction Patient reminded of this, says oh yeah and discharged home on cephalexin (i.e. a cephalosporin she was allegedly allergic to) Solution allow patient to access their own EHR remotely and give permission for access to enhance care
21 Archived EMR/Print EMR different than live view Fixes to EMR unintended consequences
22 Data streaming Late documentation how is that defined? Inconsistent utilization across providers Metadata/Audit trail Medical errors 1.1% due to errors in EMR Wrong patient documentation
23 Clear, consistent, credible documentation Documentation policy/chain of command Report safety hazards associated w/ EMR
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25 Hospital documentation policy should address and be followed
26 10/26/14 at 1600 Pertinent physical findings: numbness to RUE. Cap refill wnl, mod grips. Dim bases of lungs. RRT called due to chest tightness, SOB, radiating pain between shoulder blades down spine and increased pain in jaw. Elevated BP since admission. Pt. Reports feeling like she was having a panic attack. Troponin and EKG negative, CXR showing R hemi diaphragm irritation likely due to PNB and phrenic nerve irritation per MD notes. Hydralazine ordered and administered at 1707 with little effect. MD aware. Continue to monitor. Panic. Sx resolved. 10/29/14 at 1500 Pertinent physical findings: numbness to RUE. Cap refill wnl, mod grips. Dim bases of lungs. RRT called due to chest tightness, SOB, radiating pain between shoulder blades down spine and increased pain in jaw. Elevated BP since admission. Pt. Reports feeling like she was having a panic attack. Troponin and EKG negative, CXR showing R hemi diaphragm irritation likely due to PNB and phrenic nerve irritation per MD notes. Continue to monitor.
27 PT note for 10/20/14 BB last seen on August 20th, From that visit: 27 year old male lower extremity weakness need to obtain his records to review his MRI. targeted physical therapy. Discussed and encouraged patient to do core exercises at home. BB is here today for a followup visit.
28 q2 hr documentation during the night 2000 Respirations: unlabored 2200 Respirations: unlabored 0000 Respirations: unlabored 0200 Respirations: unlabored 0400 Respirations: unlabored 0600 Respirations: unlabored BLUE
29 The EMR sees all Meta data/audit trail Label all late entries Identify reason for late entry
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31 Patient discharged 01/18/14 The following documented on 01/21/14: Late Entry for 1/18/14 Addendum to end of shift summary [Very long, detailed information of almost a full page followed]
32 1000 on 01/18/14 Late entry for /18/14 unable to chart in real time due to pt acuity
33 Late Entries Include the reason the late entry is being made Reference the date/time to which the entry is referring Late entries which are not clearly identified as such can compromise the credibility of the author
34 Tell your version of the patient care story Answer questions that might be asked about what you did or what events occurred during your shift
35 69 yo male with GI concerns 0400: Cognitive: Confused, difficulty comprehending. 0500: Provider Notification: Dr. Smith paged. 0745: Cognitive: Late entry, Lethargic, disoriented, not responding to verbal stimuli.
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37 Does your documentation reflect what you intended it to say? Can I, as a reviewer, understand your thought process from your documentation?
38 Nurse documented physician called. Nurse said she called the physician to report an abnormal lab value. Physician said he called the nurse to ask about the patient s status.
39 Metadata of EMR showed that the nurse had been in the lab section prior to her note. Metadata of EMR showed that the physician had not accessed patient s EMR for two days.
40 Outdated terminology, jargon Abbreviations Legibility (or voice recognition software) Would the patient understand?
41 Uneventful day no c/o N&V tolerating general diet well walked with PT around noon tolerated well also walked again this afternoon with RN pt had low grade fever tylenol given MD notified urine and blood cultures obtained IV antibiotic started will continue monitoring
42 My chart - maybe Incident reports or unusual occurrence reports Social media posts Diary or ancillary notes in your locker Texting and s
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44 Use consistent format Label late entries including reason Be respectful of patient and other providers Answer all questions related to patient care
45 Clear Concise Credible
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47 Barbara Hansen
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