Whether you are an experienced nurse or recent grad, documentation can be challenging. Here is some information that can assist with improving your charting and reducing liability risks:
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Documentation is a core nursing competency, which helps to ensure that patients receive appropriate, high-quality health care services. While it may be difficult to find time for nurses to document patient care in addition to their other clinical and administrative responsibilities, one of the nurse’s primary professional responsibilities is to maintain consistent documentation. Documentation provides a picture of the patient’s condition and how they respond to treatment, which influences the decisions that subsequent providers will make regarding the patient’s care. It is also a legal record that reflects the quality of care you provided.
Defensive Documentation Can Help Protect Nurses from Liability
In a litigious and ever-shifting healthcare landscape, nurses face potential liability in their everyday work. Documentation is a tool for the planning and provision of patient care, communication among providers, and demonstration of compliance with federal, state, third-party payer and other regulations. Inadequate documentation may not only impede the quality of patient care, it can also hinder the nurse’s legal defense in the event of a malpractice lawsuit and can even lead to a nursing board license complaint. In fact, CNA and NSO’s closed claims analyses for nurses and nurse practitioners found that 9.1 percent of nurse and 6.3 percent of nurse practitioner Board of Nursing paid claims were due to allegations of documentation errors or omissions, with an average defense expense of $4,124 and $6,782 per claim, respectively.
Enhance your documentation practices
A complete and accurate clinical record presents the strongest defense against any malpractice or licensing board action. While some specialized settings, practice arenas, regulations and other areas may require additional types or components of documentation, the following principles may lessen nurses’ liability exposures:
- Chart in the correct record. Ensure that key patient identifiers are accurate, including the spelling of the patient’s name and their date of birth, to ensure effective linking of patient healthcare information records within and across systems.
- Chart promptly. As soon as possible after you make an observation or provide care, document your actions for more detailed notes. If you wait until the end of your shift, you could forget to include important information.
- Be accurate, objective, and complete. Document what you see, hear, and do. Include data relating to all aspects of patient care and the nursing process. Refrain from documenting inappropriate, subjective opinions, conclusions, or derogatory statements about patients, colleagues, or other members of the patient care team.
- Track test results and consultation reports. Ensure that findings are properly communicated and acknowledged, documenting these actions in the patient’s health information record.
- Avoid repetitive copying and pasting. This is especially important when documenting high-risk items, such as laboratory results, radiology reports and drug formulations.
- Use approved abbreviations. Unfamiliar or seldom-used abbreviations can confuse other caregivers and lead to potential patient injuries. Ask to see your facility's list of approved abbreviations. Familiarize yourself with them and use them consistently.
- Include patient communication. Document patient education regarding treatment and any educational materials, resources, or references provided to the patient. Patient complaints, questions, and other concerns should also be documented, as well as all steps taken to resolve their concerns.
- Record instances of non-adherence. This includes missed appointments, refusal to provide information, and rejection of treatment recommendations. Be sure to report this to your manager and the patient's primary provider.
- Document delegated tasks. Include verification that delegated patient care-related tasks are completed by those who are under your direction and/or supervision.
- Correct errors promptly. Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
- Safeguard patient healthcare records. Comply with your organization’s information security practices to protect patients’ healthcare information from loss and/or unauthorized access.
Your documentation should be consistent with the treatment plan(s), and meet federal, state, and local law, as well as all applicable professional and ethical guidelines. It should also reflect established coding and billing procedures. Contact your manager, supervisor, or risk manager for assistance with documentation concerns or questions, especially if they may have liability or regulatory implications.
For more information on documentation and professional liability, please consider some of our other resources available in the NSO Learning Center:
By Georgia Reiner, Risk Specialist, NSO