Nursing Documentation

1. Unraveling the Mystery of
Nursing Documentation
Wanda Sanchez, MSN, RN, MBA, ANP-BC
Evangelina Ramirez MSN, RN, CCRN
Clinical Nurse Educator

2. Documentation
Or….You want this chart to be your friend

3. Documentation
• Bad documentation can make good nursing
look bad and can make bad nursing look even
worse.
• Five years from now, you probably won’t
remember the patient you had yesterday. All
you will be able to depend on is your notes.

4. • If that statement makes you feel better then
you are probably doing a decent job of
documenting.
• If that statement gives you the willies, then we
need to re-visit your documentation skills

5. Objectives
• Determine the legal responsibility and
accountability of the nurse in documentation.
• Support quality of care through documentation.
• Reduce risk in documentation
• Validation through documentation
• Comparison of paper documentation versus
electronic documentation
• How to use the nursing process in documentation
• Use of actual case studies to clarify appropriate
documentation.

6. Significance
• Legal Proof of the nature and quality of care
• May be the focus of inquiry in injury, malpractice or
liability claims
• Complete records will defend you against
allegations of negligence, improper treatment or
omissions in care

7. What if you see the following charted?
“The patient was LTBB.”
What do you think that MEANS????

8. LTBB is not an approved
abbreviation:
DO YOU KNOW WHAT IT MEANS?

9. LTBB means:
LUCKY TO BE BREATHING!

10. WE ARE ALL PROBABLY LUCKY
TO BE BREATHING (LTBB)
But we would never chart this (Hopefully)
Has it happened?
Yes it has happened and then it was a mystery to
unravel what LTBB actually meant.
Would you as a nurse want to explain in court to a
jury that you charted LTBB and then have to tell a
jury/judge what LTBB means?

11. Significance
Failure to document implies failure to
provide care

12. Documentation Provides
• Written evidence of interactions, treatments,
procedures and patient’s response to them
• Communication with other health care
providers

13. • Nursing documentation is an important part
of clinical documentation and is a
fundamental nursing responsibility with
professional, legal and financial
ramifications.

14. Objectives in Documentation in Nursing
Practice
• To show evidence of provision of quality health
care
• Advancement of efficient and effective health
services programs
• Creation of a legal record of nursing
services/treatments/communications provided
to patients.

15. How Medical Records are Viewed
• There is a presumption that a medical record is
accurate if no evidence of fraud or tampering is
noted.
• Medical records that are intact, sequential, and
organized supports a presumption of “quality
care.”

16. Legal Pitfalls of Improper Documentation
• Faulty record keeping practices;
• Absence of information;
• Charting after the fact;
• Missing records, time gaps;
• Vague Entries;
• Late Entries;
• Improper corrections;

17. Legal
• Unauthorized entries;
• Use of unauthorized medical abbreviations;
• Documenting personal opinions;
• Writing is illegible
• Hospital loses money due to improper and/or failure
to correctly input proper diagnostic codes.

18. How to Avoid the Legal Pitfalls of Documentation
– Number, Date and Sign all entries;
– Write legibly;
– Use generally accepted standard medical
abbreviations;
– Document immediately or soon thereafter when
caring for your patients;
– Document what you see, hear, feel and smell;
– Avoid innuendo;

19. How to Avoid the Legal Pitfalls of
Documentation
– Avoid use of liquid paper or correction tape;
– Avoid use of pencil;
– Do not chart for others;
– Enter appropriate codes;
– Follow proper policies and procedures for
documentation

20. How to Avoid the Legal Pitfalls of
Documentation (cont)
– Make corrections following appropriate guidelines;
– Avoid tampering with records;
– Follow hospital policies for handling verbal orders,
telephone orders, etc.
– Do not leave blank spaces for others to later add
entries;
– After charting, avoid divulging confidential
information to “others.”

21. How to Avoid the Legal Pitfalls of
Documentation (cont)
• Use appropriate punctuation and grammar.
• Double check patient information;
• If computerized charting is utilized in your
institutions, take measures to safeguard your
personal code.
• Maintain patient privacy
• Avoid derogatory comments on charting
systems.

22. GENERAL TIPS FOR AVOIDING
LIABILITY
• Maintain prudent documentation and healthcare
practices
• Be familiar with policies and procedures re:
charting and documentation of your health care
facility
• Establish a good rapport with your patients
• Write legibly
• Document factual information
• Write proficiently, use proper grammar and
punctuation.

23. Assessments
• Full shift assessments should be done at the
beginning of the shift and after a fall
• Focused assessments should be done as per
your unit protocol every 4 hours in critical care

24. Narrative charting
• Your first note should be fairly extensive and
should “paint a picture” of what the patient
status is, your view of their initial assessment,
any outstanding or unresolved problems

25. First note
This is where you document your lines, drips, rhythms,
pressures, etc. i.e.
54 year old male in with diagnosis pancreatitis under service Dr.
Feelgood. Admitted to hospital and this unit on 12/1/08.
Patient awake, responsive, moves all extremities purposefully.
Complains of abdominal pain and vomiting. Skin color icteric
warm dry. IV’s as follows:
Left subclavian triple lumen
NS at 120
Dopamine infusion at 7 mcg/kg/min
CVP Pressure readings done on 3rd port

26. Continued
NGT in place, verified though auscultation of air bubble and
return of gastric contents. Connected to Low
continuous suction draining small amounts green
drainage. Foley catheter patent draining clear yellow
urine in amounts greater than 30cc/hr
Medicated with Demerol 25mg IV at 0730 for c/o abdominal
pain, will recheck in 15 minutes for relief of pain.

27. More documentation
Don’t forget to write that the Plan of care was
discussed with patient and that they agreed to
same. Also, note any teaching including
content and response and who was the
recipient of the information.

28. Fine ART of NURSING
DOCUMENTATION.
• Why do we document?
• We document to paint a clear and unbiased picture of
our patient.
• We document to pass on important information to our
colleagues.
• We use documentation in a collaborative effort to care
for our patient through interdisciplinary teams.
• We document to reduce risks.
• We document to support quality of care for each patient.
• We document to protect our patient and ourselves.
• We document to maintain effective communication
among team members.

29. What happens if we do not
document?
• Errors are made.
• There is confusion.
• We have no record of what happened with our
patient on a shift by shift, day by day basis.
• We have no legal basis on which to stand and
support what we as nurses have done to care
for this patient.
• We do not effectively communicate.

30. Your license may depend on good
documentation:
Maybe you did what you as a nurse and
professional should have done.
The question is: How do you prove it?

31. The answer is:
• You can not validate nor prove that you did what you
were supposed to do unless you documented it.
• This goes along with the tried and true statement of, “If
you did not document it, you did not do it.”

32. The DO’S of charting/documenting
• Make sure you have opened the correct chart.
• Make sure you are documenting the
information on the correct patient.
• Chart in a chronological manner.
• Do not wait to the end of the shift to document
as you will forget something.
• Use the nursing process.
• For every action there must be an interaction.
• Chart the care at the time you give the care.
• Document a clear and concise picture.

33. More documentation
• Don’t forget to write that the Plan of care was
discussed with patient and that they agreed to
same. Also, note any teaching including
content and response and who was the
recipient of the information.

34. DON’T/S
• Do not chart a symptom such as c/o of pain
without charting an intervention.
• Do not ever alter a charted document as this is
a criminal offense.
• Do not chart what someone else said.
• Chart what you know to be a fact as it relates
to your patient.
• Do not chart in advance, what if something
happens and you can not complete the care
you have already charted?
• Chart in precise language, watch out for
unapproved abbreviations and indistinct
shorthand.

35. Common Allegations
Made Against Nurses
 Patient Falls
 Failure to monitor
 Medication errors/Poor documentation
 Equipment injuries
 Failure to follow hospital policies and procedures
 Failure to ensure patient safety
 Failure to report a change in patient’s status
 Explore allegations in the various health care
settings

36. Factors that Prompt
Families to Sue
 Nurse’s attitude is insensitive or he/she ignores a
patient’s complaints
 Nurse fails to meet patients needs throughout
the course of their hospitalization
 Nurse is inflexible and does not communicate
well with patient and/or family members
 Nurse exceeds boundaries and limits of practice

37. Typical Profile of a Litigious Plaintiff
 Openly expresses hostility or anger at
members of the health care team
 Highly critical regarding all aspects of nursing
care
 Overreacts to any comments made
 Blames staff for any and all negative events
which have occurred
 Has a history of filing lawsuits

38. Strategies to curtail or prevent suits
Establish a good rapport with your patients
Follow the ANA’s Moral Principles
 Respect
 Autonomy
 Beneficence
 Non-Maleficence
 Veracity and Confidentiality
 Fidelity and Privacy
 Justice

39. Strategies cont.
 Instill patient confidence
 Keep patient and families informed of care
issues
 Be attentive, sincere and display a genuine
sense of warmth
 Maintain a professional demeanor at all
times
 Note: 75% of decisions to sue center on
poor attitudes and poor communication.
These are often the most costly civil type
actions!

40. Impact of Standards of Nursing Practice
 Standards of Practice serve as a legal yardstick to
measuring our course of practice
 They serve as “minimum”guidelines for dictating
the boundaries of our practice
 For legal purposes, they measure the
performance of nurses with that of a “reasonably
prudent nurse”
 Each specialty of nursing may have their own
individualized SOP
 SOP may change periodically

41. Standards of Nursing Practice Cont.
 SOP are sometimes confused with clinical
guidelines or professional performance
standards
 Note the differences:
 SOC: are standards used to measure whether
nurses are following the nursing process
 SOPP: are standards relating to the professional
behavior of nurses
 Clinical Guidelines: are pt focused and
determine if the nurse is carrying out the
recommended course of action

42. Board of Nurses Standards
 RN Board: Section 217.11 of the NPA addresses
minimum Standards of Professional Nursing
Practice applicable to ALL nurses
 Section 217.12 addresses what constitutes
“unprofessional conduct” for both RNs & LVNs
licensed in Texas

43. Examples of NPA violations
 A nurse’s patient stopped breathing, the nurse
left to gather supplies rather than initiate the
Code and asks others to begin the Code. Two
minutes lapsed from the time pt stopped
breathing and when the nurse asked others
to initiate CPR
 An RN delegated an IM injection to an aide.
The RN did not supervise the injection and the
pts. sciatic nerve was damaged

44. Examples Cont.
 The nurse was required to visit all home
health clients within an allotted time. The
nurse ran behind and instead of personally
visiting all of the pts, the nurse called the
patients. The nurse then documented that he
had visited all the pts and thus Medicare was
“fraudulently” billed for all these visits
 A nurse was ordered to administer Valium IV.
She administered too rapidly causing pts
pulse ox and respirations to drop. She
admitted that she had never administered this
drug and didn’t know how long or slow it
needed to be given over

45. Violations of NPA will subject Nurses to Investigation
by the BNE
Boards actions are administrative in nature
Lawsuits against Nurses are deemed civil in nature
At the board level, violations will prompt the BNE to
institute the investigation process which involves
the following steps:
 Complaint filed
 Nurse informed of allegations in writing and
asked to respond
 Case will be reviewed and either dismissed or
informal conference may be requested
 After conf, case may be dismissed or discipline
recommended

46. Who is responsible for reporting to the
BNE
 Consumers
 Health care providers other than RN’s
 Attorneys
 Health care entities

47. Who is Required to Report
Complaints to the BNE
 RNs have a duty to report
 Peer Review Committees
 Health Care entities
 Professional Associations and Organizations
 State Agencies
 Professional Liability Insurers
 Prosecuting Attorney for Criminal convictions

48. Harsh Realities
 Know your states NPA READ, READ,
READ!
 The NPA can be your best friend or your
worst enemy
 The NPA will be what attorneys will be
looking to if you are ever named in a civil
lawsuit
 Your license is a property interest that the
board can issue and also strip away

49. Harsh Realities Cont.
 Aside from disciplinary measures from the
BNE, nurses can be held criminally or civilly
liable for their actions. As such they can and
are being sued in court
 Civil Liability results when a nurse failed to
act or acted, but in a negligent manner
 Criminal Liability arises when a nurse
commits a crime against the state such as
murder, assault, battery, theft, or DWI
 Each type of liability can lead to the other

50. Civil Liability
 Of the various areas of civil law, the area
which impacts nurses most is tort law
 Tort defined: a civil wrong committed
against another individual
 Torts can be intentional or unintentional
 Ex of intentional torts: false
imprisonment, invasion of privacy,
assault, battery, slander
 Ex of unintentional tort:
negligence/malpractice

51. Civil Liability Cont.
 Negligence: failure to act as a reasonably
prudent nurse would have acted in the same or
similar circumstances.
 Gross Negligence: a nurses intentional failure
to perform a duty and recklessly disregarded
such duty
 Nursing Malpractice is a subpart of negligence
and can also involve a nurse’s failure to protect a
patient from risk or harm or when the nurse fails
to meet the standard of professional nursing
practice

52. Malpractice Claims Against Nurses
 The ANA has reported that nursing
malpractice awards have totaled about
$145,000
 A few have reached the million dollar mark!
 In order for a plaintiff to be successful in a
malpractice suit, he or she must prove 4
essential components, otherwise the claim
will dismissed.

53. 4 Components of Negligence
 Duty
 Breach of Duty
 Causation
 Damages

54. Parties Involved in the Lawsuit Process
 Plaintiff (s): person or persons initiating lawsuit
 Defendant(s): person or persons against whom
the lawsuit is TARGETING
 Witnesses: anyone closely or remotely involved
with the case
 Experts: witnesses utilized in lawsuits to rebut or
offer specific testimony
 Judge: person who oversees the trial process
 Juries: panel of individuals who decide the fate of
the Defendant(s)

55. Timeline for Filing a Lawsuit
 Statute of Limitations: is the time frame for
filing a lawsuit. Texas has a 2 year SOL.
Typically, lawsuits brought after the 2 year
period will be forever barred.
 Exceptions:
 Fraudulent Concealment
 Discovery Rule
 Minors
 Plaintiff must file Notice of Healthcare Liability
in accordance with Chapter 74 of the Tex. Civ.
Prac. & Remedies Code.

56. Anatomy of a Malpractice Suit
 Most cases settle before ever going to trial
 Those that don’t settle will proceed to trial
 The trial process involves a series of events
 Voir Dire
 Opening Statements
 Presentation of Plaintiff’s Case
 Presentation of Defendant’s Case
 Closing and Deliberations

57. Proceedings Cont.
 Once a lawsuit is initiated, the discovery process
will take place and includes:
 Depositions
 Interrogatories
 Requests for Production, Interrogatories,
Requests for Disclosure
 Mediation Conferences

58. Remember
• Negligence can be based in the fact of
omission and / or co-mission.
• Omission because we forgot to do something
or we simply did not do something. We omitted
it!
• Co-mission because we did something we
should not have done, we did it late causing a
delay in care or we did it wrong.

59. WE ARE ALL PROBABLY LUCKY
TO BE BREATHING (LTBB)
• But we would never chart this, document this for
our patient’s.
• Has it happened?
• Yes it has happened and then it was a mystery to
unravel what LTBB actually meant.
• Would you as a nurse want to explain in court to a
jury that you charted LTBB and then have to tell a
jury/judge what LTBB means?

60. • As cited in an AJN article, there are many ‘gaps’ in
clinical documentation with patient’s responses,
outcomes and actions often not included as current
nursing documentation.
• As the article noted documentation must also include
evidence of assessment and patient progress.
• Despite the trend to streamline clinical records to
improve compliance with nursing documentation,
there is a real concern that nurses are not reflecting
the holistic nature of their practice and work.

61. Example
• The patient was complaining of pain on a scale of 4 out
of 10 using the pain scale.
– What did you do?
• You gave pain medication as ordered.
– But then what?
• You must reassess the patient within let’s say 1 hour to
see if their pain has improved. Right?
• If you do not reassess how do you know the intervention
was helpful to the patient?
• Perhaps you need to notify the physician for additional
orders if the pain medication was not effective.

62. • What if the patient sues the nurse and the
hospital because he/she claims to have been in
unbearable pain for 2 days.
• How do you know if this is true or not?
• Is this a legitimate claim?
• If you did not record patient’s response to the
intervention of giving the pain medication but you
are consistently giving pain medications without
further intervention on behalf of the patient then
you look guilty in the fact that you did not
advocate for the patient thus you dropped the
standard of care. Right?

63. So, What’s the Problem????
Documentation is often seen as taking time
away from nursing care rather than being
a part of nursing practice and care.

64. Use the nursing process to
document:
• The words you choose in charting today could
come back to haunt you tomorrow and many
tomorrows thereafter up to 7 years depending
on the statute used.

65. Nursing Process Steps:
• Assessment. This is the first step of the nursing
process. It involves the systematic and continuous
collection, validation (evaluation) and selection of data.
• Nursing Diagnosis. From the assessment of functional
health patterns human response patterns are identified
and classified according to statements of actual, high
risk and possible problems, and wellness diagnoses
• Planning. Specification of client goals to promote health
and/or prevent, reduce, or resolve the problems that are
identified in the nursing diagnoses, and related nursing
interventions.
• Intervention. Implementing the plan of care
• Evaluation. Measures the extent to which the
patient/client has achieved the goals specified in the
plan of care, and identifies the factors that positively or
negatively influenced goal achievement.

66. Document, document and document
should be the mantra around all care
activities.
• Moreover, documentation needs to go beyond
what was actually performed, to include the
thoughts, statements and intentions of both the
provider and the care recipient.
• Documentation should reflect this shared effort.

67. Document Everything Pertinent
Moreover, documentation needs to go beyond
what was actually performed, to include the
thoughts, statements and intentions of both the
provider and the care recipient.
• Documentation should reflect this shared effort.

68. How to protect your license
• Accurate Documentation
• Factual Documentation
• Complete Documentation
• Abbreviations
(use only approved)
• Unsolved Mysteries ( avoid them) do not keep the
reader guessing!
• Criticism
(avoid it)
• Corrections and Late Entries ( Be specific)
• Confidentiality
Coordination of Care (when did you call the physician
and why/ for what reason?)

69. Case Study
• The plaintiff’s decedent, age seventy-eight, was a
resident at the defendant’s nursing home. She
complained of dizziness and nausea in December 2004.
No vital signs or blood count were taken.
• The next day, the decedent was found unconscious with
blood on her sheets, pillows and adult diaper.
• The plaintiff claimed that the blood-soaked articles were
removed and the decedent was cleaned up before her
family was contacted.
• The decedent’s daughter claimed that she was told that
her mother had died of a heart attack.
• The chart entry on the death only noted that the
decedent was found without respiration and no mention
was made of her bloody condition.

70. What did the autopsy tell?
• An autopsy found that the death was due to a
gastrointestinal hemorrhage and that she had
probably been bleeding internally for several
days.
• The plaintiff claimed that several entries in the
decedent’s chart were false, including a
notation that the decedent had received an
insulin shot an hour before her death, and late
entries concerning bleeding which were made
by nurses who were not even on duty.

71. What do you think happened in this
case?
• According to a published account a jury returned a
$54 million verdict, which included $4 million in
compensatory damages and $50 million in punitive
damages.
• Eighty percent of fault was assessed against the
facility and twenty percent was assessed against
two nurses.
• With permission from Medical Malpractice Verdicts,
Settlements & Experts; Lewis Laska, Editor, 901
Church St., Nashville, TN 37203-3411, 1-800-298

72. Another Case Study
• The plaintiff’s decedent, age fifty-nine,
underwent an elective outpatient knee surgery
in March 2003 at the defendant hospital.
• The surgery was reportedly uneventful.
• However, while in the post-anesthesia care unit
her blood pressure began to steadily increase.
She soon stopped breathing.
• The defendant, the nurse in the unit,
administered Narcan to the patient.

73. Snap shot of the case:
• The blood pressure spiked to 287/169. The
plaintiff claimed that this caused the capillaries
in her brain to leak fluid and her brain to swell
against her skull.
• A call for a physician was made eleven
minutes after she stopped breathing and a
physician responded three minutes later.
• Medication was administered to counteract the
Narcan (????).
• The decedent had suffered brain damage and
was in a permanent vegetative state.
• Life support was removed two days later.
• The woman died four days after the surgery.

74. What do you think happened here?
• Where was the standard of care dropped?
• What is the issue in the delayed call to the
physician?
• Do you see negligence?
• How could this have been prevented?
• Would you have an issue with this type of
documentation?

75. What did they all have to say?
• The plaintiffs alleged negligence by the nurse in failing
to call a code or to immediately alert a physician for
eleven minutes, during which brain injury resulted.
• The defendants argued that the nurse had immediately
called for a physician, but received no response.
• The nurse claimed that she had simply followed the
orders of the certified nurse anesthetist in the unit when
a physician did not immediately appear after her first
call. The defendants also contended that the decedent
had actually died due to an extremely rare tumor in her
adrenal glands, which caused her blood pressure to
spike.
• An autopsy did not reveal any tumor.

76. What do you think happened?
• Did the nurse simply follow orders?
• Did the nurse delay care?
• Did the nurse anesthetist fail in her duties?
• Did the nurse fail in her duties?
• Did the physician/surgeon drop the ball on this
one?
• There was minimal to no documentation to
support anyone’s claims that they did their job.
• What is your conclusion?

77. Results
• According to a report, a $675,000 verdict was
returned against the nurse.
• $1 million against the facility.
• $1 million against the Nurse Anesthetist
• $2 million against the facility.

78. Case Study
• The plaintiff’s decedent underwent neck surgery in
January 2003 which was performed at a Medical Center.
• The decedent’s family claimed that he was fine in the
recovery room.
• After transfer to his room the decedent began
experiencing respiratory distress.
• His family claimed that the problems started an hour
earlier than the hospital staff maintained that the
problems began. The decedent went into respiratory
arrest and a code was called.
• He was eventually placed on life support and he died at
the hospital when life support was removed about ten
days later.

79. What happened?
• It is a mystery because there are no
documentation notes to support what
happened after the transfer until the patient
arrested.
• The notes were created after the fact.
• The assessment was not done initially or
documented initially.
• Who dropped the ball on this one?
• Tell me your thoughts?

80. The allegations:
• The plaintiffs alleged negligence by the
hospital staff in failing to properly monitor the
decedent after his arrival in the room.
• The plaintiffs also claimed that the nurses
failed to notify the attending physician of
problems in a timely manner.
• Note that the vital signs were added in as a
late entry into the documentation for this
patient.
• What do you think that problem was in this
scenario?

81. Defendants claims:
• The defendants generally denied any
negligence and claimed that preexisting
conditions and superseding events outside the
hospital’s control caused the death.

82. End Result:
• According to a published account a $2,225,000
verdict was returned and this became a
licensing issue for the nurses involved.

83. Bottom Line
• Due to financial pressures in healthcare,
nursing services have a mandate of efficiency
and measurability.
• Why do you think this has happened?
• The implementation of standardized
languages, nursing diagnoses, and outcomes
allows for increased practicality and efficiency
of nursing data management.

84. • The definition of a nursing diagnosis is “a clinical
judgment about an individual, a family or a
community’s response to actual and potential
health problems/ life processes.”

85. What does all of this mean?
• Nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.
• Nursing interventions are regarded as nursing
treatment which are based on clinical judgment
and knowledge and which are carried out by
nurses in order to improve patient outcomes.
• Nursing Outcomes are described as changes
in the patient’s health as a result of nursing
interventions.
• Defining aspects of nursing outcomes are
regarded as measurable or observable results
across a time period.

86. • One of the measures of quality for nursing
outcomes is to link them with nursing diagnoses
and intervention and evaluate them in that context
(National Academy Press,1999).

87. The computer age
• Electronic health care records have made a
major difference in the lives of the practicing
nursing professional.
• We now have built in screens with prompts to
let us know that a specific area of
documentation is needed.
• The problem is that we as nurses learn to
circumvent the system.
• When we do this we are more prone to
mistakes in our documentation.

88. Electronic charting
• “EHR charting is more structured; you’re forced
to choose from various options in multiple lists
(drop down lists). You have to change your
thinking about charting.”
• That doesn’t lessen your responsibility to
document thoroughly and accurately, so you
must understand how the system works and
use it properly.

89. Always remember:
• When properly implemented, information
technology can
• simplify information retrieval, reduce medical
errors, and
• improve communication, among other pluses.
• But information
• technology doesn’t eliminate the need for
professional
• judgment.

90. Keep in Mind!
• “People are not infallible.
• Neither are computers—
• But we tend to think they are,” said Melanie
Balestra, JD, MN, NP, a California-based
attorney.

91. Some potential pitfalls of EHRs
• Compared with paper records, an EHR can
store more information for longer periods.
• Also, an EHR is accessible concurrently from
many workstations and can provide medical
alerts and reminders.
• Despite these and other advantages, an EHR
can make one of your key responsibilities—
documenting patient care—more difficult.
• “Traditional paper charting is free-form and
leaves more room for errors.

92. • You have to change your thinking about charting.”
• That doesn’t lessen your responsibility to document
thoroughly and accurately, so you must understand
how the system works and use it properly.
• “For instance, what if you enter something into the
wrong patient’s chart?”
• What do you do? What do you do on paper and what
do you do in the electronic record?

93. Paper vs EHR
• On paper you’d line through the entry once and
initial or sign it, but you can’t do that in an
EHR.
• And, if you are able to make a correction, will
the system still save the mistake?”
• What is our process at Del Sol?

94. • If you record the information in two different places
and make a mistake in one of them, you introduce a
conflict.
• Whether you can correct charting mistakes easily or at
all may depend on the safeguards built into the
system.

95. What records are legally valid?
• Remember that reports or other documents
transmitted via “low-tech” e-mail or fax can be
just as legally valid as paper originals or
records stored in an EHR.
• “They’ll generally hold up in court as long as
automatic date stamps or other systems are in
place to prove they’re authentic and weren’t
altered.”
• Also any documents that you mention in your
nursing notes may be discoverable if an
attorney picks up on this information.

96. • A patient’s medical record can be subpoenaed in
court and the information that has not been recorded
could prove as useful as the documented record.

97. • With all patient-related documents, whether paper or
electronic, taking appropriate security measures to
protect privacy remains a top priority!!!!!!
• To comply with the regulations of the Health
Insurance Portability and Accountability Act (HIPAA),
you must Do everything possible to prevent
unauthorized people from viewing patients’ health
information.

98. How do you document in your
notes?
You have a 29 year old female admitted to your medical
surgical unit at 0900 hours.
The primary medical diagnosis is anemia of unknown
origin.
Vital signs T 98.1, P72 R 24 B/P 120/60 initially
The patient is pale, warm and dry. 0945 She is crying
because she is frightened and does not want to be in
the hospital. One hour into the shift you note the patient
is in the bathroom vomiting, you smell blood and
proceed to look at the toilet contents. You see bright red
blood in a moderate amount. The time is 10 am. 0930
Your head to toe assessment at 0900 hours is
unremarkable.
Document this: Use the nursing process!

99. References
Kohn LT, Corrigan JM and Donaldson MS, Editors. To Err is Human: Building a
Safer Health System. Washington, DC: National Academy Press. 1999.
Centers for Disease Control and Prevention (National Center for health Statistics)
Deaths: Final Data for 1997. National Vital Statistics Reports: 47:19) 27.
Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in
hospitalized patients. JAMA. 277:307-311, 1997.
Hanka, R. (1997). Information overload and 'just-in-time' knowledge. Center for
Clinical Informatics. Retrieved on July 7, 2003 from
http://www.medinfo.cam.ac.uk/miu/papers/hanka/mic97/just_in_time.html
Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901
Church St., Nashville, TN 37203-3411, 1-800-298
Ash JS, Berg M, Coiera E, et al. Some unintended
consequences of information technology in health
care: the nature of patient care information system related
errors. J Am Med Inform Assoc. 2004; 11,

100. Test Taking for this course:
• You will be given 3 case scenarios using a
performance based data system and are
required to document on each scenario as if
you were the nurse and the person in the
scenario was your patient.
• Please document as you would if you were the
primary nurse for this patient.
• Use the nursing process and remember we
must always document for a jury! Just in
case…..

101. NPA
• But, there is more to this story
• Here is some of the stuff you haven’t heard yet

103. NPA

104. NPA
• Action taken against nurses licensure can take
many forms, but a couple of the big issues are
failure to document, failure to inform, failure to
rescue.

105. • Chart Check, Medication wastage