In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court.
Recently, a home care nurse was called to testify in a trial involving a medication she gave to her patient four years prior to her testimony. During that time, she cared for hundreds of patients and provided thousands of visits. Without factual and accurate documentation, it would have been difficult to recall exactly what happened four months ago, let alone four years ago. Fortunately, her documentation was very specific and was a large factor in the dismissal of the case.
1. Accurate documentation
The closer the documentation is recorded to the actual event, the more reliable it is. Agency policies should define how soon after the visit the documentation must be recorded. Agencies that allow staff to document their activities at the end of the day when they are tired and in a hurry (or at the end of the week to "catch up" on documentation) risk ending up with inaccurate notes.
2. Factual documentation
Agency staff should state the facts by using objective, not subjective, terms. Advise staff to record their senses (touch, feel, and smell), the patient's actual words, and use specific measurements.
3. Complete documentation
Look to industry standards of practice to identify comprehensive documentation. For example, document wound measurements at least weekly, and weight, edema, and lung sounds at each visit with a patient with a primary diagnosis of congestive heart failure. Avoid the use of vague terms like "raw" wound, "healing well," "small," "moderate," or "large" amount of drainage, and use objective terms. For example, staff should document the specific length, width, and depth of the wound ("9x5x1cm") or, for a small wound, compare it to a common object ("size of a dime"). Drainage could be documented as "saturates 2 4x4s in a 24-hour period.
4. Clear abbreviations
Although abbreviations can reduce documentation time, agencies should not allow notes to turn into a foreign language that no one can interpret. Use only agency-approved abbreviations and conform them to generally accepted lists.
5. No unsolved mysteries
Do not leave the reader guessing. Describe gaps in service caused by missed visits or hospitalizations. Document communication with physicians or other clinicians related to new findings or changes in the patient's condition. Nearly every type of external audit compares the services documented with those ordered in the plan of care. Auditors always raise questions when the last note in a patient's file indicates that the nurse or therapist will visit in two days, yet, no visit occurs for a week or longer and the documentation contains no explanation of what happened. The reader is left trying to guess whether the patient was forgotten on the schedule, the clinician forgot to write a note, or the patient disappeared.
6. Avoid criticism
Avoid criticizing other agency staff, the patient, and/or caregiver in your clinical documentation. One agency nurse wrote in the medical record that the physical therapist "really screwed up," and a home health social worker called her patient "obnoxious and belligerent." Patients in most states have the right to review their clinical records; therefore, staff must be careful about what they document. Performance information should be reported to the employee's supervisor and documented in the personnel record; incident reports should be documented according to agency policy, which is separate from the clinical record.
7. Handle corrections and late entries with care
Liquid paper corrections should be banned from all clinicians' offices. Despite years of reminders, this substance still appears on charts from time to time. Staff should simply draw a line through the incorrect entry and note their initials and the date. For late entries, always document the time and date of the late entry, add the entry in the first available space in the record, clearly identify it as a late entry, and cross-reference it to the original event.
8. Use confidentiality
It is important to document any special directions by the patient related to release of medical information. For example, a patient might tell the admitting nurse that she does not want her daughter to have any information about her condition. Later, the patient may change her mind and tell another nurse to explain "everything" to the daughter. If the second nurse does not document this change, the patient could later claim that the nurse breached her confidentiality by talking with the daughter.
9. Show coordination of care
Documentation should reflect all attempts to contact the physician regarding changes in a patient's condition. Include the name of the physician notified, a brief summary of the reason for the call, and the physician's response. Clinical notes frequently state the presence of changes in the patient's condition, such as elevated blood pressure or increased pain, but do not indicate that the physician was notified of these changes. In one case, a physical therapist noted that the patient's blood pressure continued to be elevated and even noted that the physician should be notified. However, the therapist never documented the fact that he contacted his supervisor, the nurse assigned to the patient, or the physician to inform them about the high blood pressure. The patient suffered a stroke the next day.
A medical record should be an organized and clearly written synopsis of a patient's course of care from admission through discharge. Like a photograph album, a medical record contains snapshots that depict the patient at different stages of his or her care. With factual, complete, and timely documentation, the medical record paints the full picture for the reader. Without it, providers create risky situations that result in potential liability.