Documentation is the collection of written or printed information providing supportive evidence of an event. The recording of events or happenings associated with an episode of nursing care is vital in order to communicate a patient's status, assess needs, formulate a plan of care, and record patient outcomes. Precise record keeping can protect the welfare of patients by promoting continuity and consistency of care (Rhodden & Bell, 2002).
The challenge today is to provide a succinct but comprehensive record that accurately portrays the patient's experience while addressing the standards of professional and organizational care, regulatory requirements, fiscal responsibility and criteria for reimbursement. This record of care, a legal document, includes information from nurses and various other health professionals whose interdisciplinary function has been to create a positive patient outcome.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has the following specific documentation standards (JCAHO, 2004):
A Registered Nurse must do the initial patient assessment.
Complete ongoing patient assessments must be done at regular specified times to determine response to treatment; when a significant change in condition occurs: and when significant change in diagnosis occurs. The assessment data is used to identify needs for care.
An Educational Assessment is required. This assessment must include comprehension level (ability to understand and answer questions), knowledge level (about health problems and how to deal with them), educational abilities (especially reading and writing), motivation, and any barriers to learning.
Nutritional Assessments and appropriate referrals are required. Although there may be no identified problems, the nurse must document that nutrition has been assessed.
Rehab Screens must also be done and documented.
One of JCAHO’s current focuses is the 2004 National Patient Safety Goals. These safety goals identify abbreviations that have been found to cause medical errors and therefore should not be used. Beginning January 1, 2004, JCAHO requires that the following items must be included on each accredited organization's "Do not use" list (JCAHO, 2004).
U (for unit)
Mistaken as zero, four or cc.
IU (for international unit)
Mistaken as IV (intravenous) or 10 (ten).
Write "international unit"
Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I".
Write "daily" and "every other day"
Trailing zero (X.0 mg) [Note: Prohibited only for medication-related notations];
Decimal point is missed.
Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
Confused for one another.
Write "morphine sulfate" or "magnesium sulfate"
Depending where you choose to work, you have undoubtedly been instructed to record patient data in a certain organized format. Follow your facility’s documentation policies. Many charting styles have been around for a long time, however some are rather new. Some institutions blend several systems together to get just the right record keeping format. Whichever style is used you need to anticipate and prepare for potential legal problems. With careful forethought these difficulties can generally be overcome with legally defensible charting strategies.
DARP/Focus charting generally requires a four-column format addressing the date, time, focus, and progress note. Each focus is written as a nursing diagnosis, sign, symptom, special need, or acute change in the patient's condition. When adequately managed, the focus areas are clearly marked as "resolved" which acts as a running tally of the patient's condition. The progress note usually follows the DAR format; "D" standing for the database; "A" standing for the action taken by the nurse; "R" standing for the result of the action; and "P" standing for the plan for further action.
This system usually requires a number of check-off forms and flow sheets to supplement the nurses' progress notes. If misused, such forms can prove problematic in court. Since this system is so different from the other methods, it may take a long time before each staff member feels comfortable with the style and therefore notes may appear inconsistent from nurse to nurse and could create potential legal problems.
Risk management strategies with this charting style are to make certain that nurses from your unit have input into the design of the check-off forms and flow sheets so that ample room is provided to record requested information. Each institution should provide the nursing staff with sufficient training to utilize this system to its best advantage.
The narrative note, the most traditional style, involves the documentation of assessment data, your interventions and patient responses in chronological order without any standardized structure, content or form. Although few facilities rely solely on this format, many narrative notes are written to supplement check-off forms and flow sheets.
The legal issues with this style are that from shift to shift, inconsistency makes it difficult to follow the patient's progress and plan appropriate care. Each nurse may write her notes with a unique style, thus making continuity of care more difficult. Since this form allows for "free-flowing" paragraphs there is also more room for sloppy writing; spelling errors; rambling; repetitive narration; inappropriate personal opinions; and inaccurate language. Although these problems are not necessarily indicative of negligence, a negative inference can be made regarding the "professionalism" of the nurse.
To avoid problems make certain that each nurse tries to achieve some consistency with record keeping. Perhaps decisions can be made regarding the placement of vital signs, patient outcomes and care rendered within the paragraph. Have a dictionary available to help with spelling problems. Handwriting must be legible and descriptions of patient observations must be precise. When flow charts are used to document vital signs avoid repeating them in the narrative unless there is a specific change that you are addressing in the note.
Clinical pathways are multidisciplinary descriptions of the expected care for a specific illness or condition within a specified timeline that is the expected length of stay. The focus is on outcomes and efficient use of resources while still providing quality care. Many healthcare professionals think that clinical pathways are just used by case managers, but this is not true. Pathways have proven to be a good way to identify variances from expected outcomes.
Typically, pathways are written to address a specific condition. It usually includes the expected length of stay, care setting, timeline, assessment, multidisciplinary interventions, patient activity, medications, lab test, patient and family education, and outcomes. Some facilities are using clinical pathways in conjunction with charting by exception. It is not clear what long-term effect that clinical pathways will have on documentation, but it is clear that they are changing documentation in many healthcare settings. Since managed care is heavily invested in clinical pathways, it is hard not to recognize their importance.
The major focus to avoid the legal complications in clinical pathways is the understanding of how your facility is using them and what supportive documentation is required. At some facilities the pathway has replaced the traditional care plan. Documentation is made directly on the pathway unless the patient does not meet the outcome. At this point a narrative note is made.
Charting by exception (CBE) was developed to overcome the recurring problem of lengthy, repetitive notes. It is a blending of narrative and flow sheet documentation. A flow sheet is used to document normal assessment findings and routine care: narrative documentation is used only to describe findings outside the norm. The flow sheet design incorporates clearly defined norms for the type of patients being cared for on the nursing units. Forms are standardized so that caregivers provide consistency in patient assessment and method of documentation. This system requires the documentation of significant or abnormal findings and does not require noting expected outcomes to nursing interventions. Charting by exception can reduce the amount of time spent on documentation.
Nurses who were trained under the mantra “if it is not charted, then it was not done” are uncomfortable with CBE (Murphy, 2003). Charting by exception seems to suggest a new motto: "all standards have been achieved with normal responses unless noted otherwise." Major education will need to be undertaken prior to implementation of this system, as many nurses are uncomfortable with the structure. The development of clear guidelines and standards is essential so that the caregiver will know when observations are "abnormal" and require noting.
Since this method is such a startling departure from other standardized charting models, it can lead to some serious legal pitfalls. The biggest problem noted seems to be the appearance of large gaps of time without patient contact. Although this is not true, if no significant observations are made, no notes will appear in the record to prove the nurse's attentiveness. Likewise, wellness promotion and preventive care will not be noted since this does not directly address a patient problem. Therefore, the nurse does not get full credit for his work. Also, the licensed practical nurse will want to make certain that his practice act is conductive to this charting method since licensing limitations can restrict the use of this system to registered nurses. The nurse must be attentive to the checklist to record the interventions or assessment of findings. “There are many legitimate arguments for and against the efficacy of a CBE system. Its legality is not one of them. When properly designed and implemented, and when tailored to incorporate any state or local requirements, there is nothing illegal about CBE” (Murphy, 2003).
Various software programs are available which are designed to capture patient data in a computerized format. Depending upon the system selected by the facility, information may be entered by keyboard, voice activation, mouse, touch-sensitive screen, or a combination of these methods. Some systems allow the nurse to select pre-written phrases to describe the patient's condition with very little sentence formation performed by the nurse.
Like any other computer application, these information systems are not perfect. Information can be scrambled, entered incorrectly, or lost completely. Computer documentation can be lost, just like paper documentation. Confidentiality issues also exist. The terminal may not be available when needed, forcing the nurse to enter information quite a while after the initial evaluation of the patient. Unless the nurse is permitted to add her own free-flowing narrative explanation, the notes can appear too similar and patient care may not appear as individualized as desired.
Ample education must be provided before implementing a computerized system. Software for medical record entry should be "non-erasable optic disk technology." Information stored on such disks cannot be altered or erased. A "hard copy" of essential information should be printed at designated times to ensure an accurate record in case of computer problems. This will be designated by the facility’s policy. Remember, error correction must be completed before the information is permanently stored. Always double-check all patient information you enter. Any corrections made after storage will have to be specially noted. Make sure that stored records have backup files-these files should be stored away from the main computer for additional risk protection.
Never leave a computer terminal unattended after you've logged in. Don't leave information about a patient on the screen when others can view the monitor. Never give your personal password or computer signature to anyone. Tell a supervisor if you suspect someone may have used your code.
Certain guidelines apply regardless of what charting style you choose. The following tips will help ensure that your record keeping can be defended in the courtroom.
Legibility is essential. Never second-guess someone else’s writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are absolutely essential, not only for safe patient care, but also because they enhance your professionalism. Make sure a dictionary is kept at the nurses’ station and post a list of commonly misspelled words. Use only abbreviations approved by your facility.
Make sure you have the correct chart before you begin writing. The medical record is considered a permanent "business record" and as such must not be made in pencil or erasable ink. Write in permanent ink. Stick to blue and black ink. As a rule, copies of the record will be used in court. Most copying machines copy blue and black ink with the most clarity. If you use a highlighter in your record (perhaps as a way of noting discontinued medication) make certain that your medical records department can effectively copy highlighted information. Some copy machines will "black out" any writing covered by highlighter. If anything is taped into the record (monitor strips, blood product labels, etc.) use double-sided tape or tape only on blank paper. Even though the tape is clear and can be read through by the naked eye, a copy machine will likely "black out" the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copying fax, the ink on the fax may be water-soluble and fade in a matter of days.
Every page of the record must have the date and patient name. This is required for a record to be admitted in a courtroom setting. Your complete signature is required once per page. Your complete signature is considered your name followed by your professional designation. When adding a progress note, follow institutional policy to determine if you are to note time that the entry is being added or the time that the observation took place. Avoid block charting, such as “11:00 p.m. to 7:00 a.m.” This type of documentation suggests vagueness. Note exact times of all critical treatments, physician contact, or notices to supervisors (Miller & Glusko, 2003). Any time you leave a message with someone in a physician’s office, note the time and the name or title of the person taking the message.
Make certain the “proper” person does the documentation. For example JCAHO requires that the initial assessment and care plan be performed and documented by a registered nurse. This is especially important in the educational, nutritional and rehab portions of the admission assessment. The licensed practical nurse or nursing assistant can document the vital signs.
Avoid documentation practices that can allow or allude to alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise when you have completed your thought, draw a line through the remainder of the line before signing your name. Do no leave blank lines between entries. Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care. To correct entries, put a single line through the error: add your initials and date of correction. You may note “error” or “mistaken entry.” Do not use white out or tape designed to obliterate typographical errors. Do not correct another’s error. Likewise, if you do not agree with an entry, do not record you opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best possible care and the chart reflects respect for all health care team members.
When possible, chart as soon as possible after you make an observation or provide care. This helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made on a following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding:
Never chart for someone else. If you did not participate in an activity or observe someone else’s care don’t write anything. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:
“At 8:35 a.m., Nurse Joann Green called and reported that at 5:30 a.m. this morning she observed…”
Understand countersigning. First, only countersign notes when required by the institution. If you merely review someone’s note, co-sign in the following manner:
“Student Nurse/entry reviewed by Jane Doe R.N.”
If you actually participate in the activity, co-sign in the following manner:
“Student Nurse/Jane Doe R.N.”
Keep the documentation objective. Don't chart opinions or assumptions. Rather than writing "the patient was unresponsive," your notes should reflect how, through objective assessment, you came to that conclusion. Did the patient respond when you called his name? Was the response based on a pinprick or painful stimuli or did he display a gag reflex during suctioning? If relating what the patient says, put it in quotation marks (Miller & Glusko, 2003). Document what you see, hear, or smell. Avoids entries like perhaps, maybe, or I think. Be careful to avoid labeling the patient. For example, avoid descriptions like demanding, drug-seeking, abusive, lazy, drunk, mean, litigious, or out-of-control. Such observations must be noted in as a description of the behaviors.
Unusual occurrences and patient injuries need to be documented. Objectively document what you witness without making any conclusions or unsubstantiated assumptions. Document the patient, roommate or visitor comments. Record the patient’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and details of treatment. However, do not mention that an incident report or occurrence report was filled out. Always chart patient’s uncooperative behavior. For example, these behaviors include:
Document any safeguards or other preventive measures you are taking to protect your patient (side rails in place; call light available, etc.).
Chart that the facility’s safekeeping system was explained and made available to the patient. Encourage patient/family to have valuables sent home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in safe are recorded on a receipt complete with the patient’s name and ID number. Describe each item in detail, using objective language for example yellow ring with clear stone instead of charting a gold diamond ring. Update valuables list frequently for long-term patients. Before a patient is transferred, take an inventory of the valuables list to verify location of items.
Document medication administration in as thorough a manner as possible. Note the date, time, your initials, the method of injection (IM, SQ, etc.), and the site of the injection. When recording intravenous (IV) infusions note the site of infusion; type and amount of fluid; medications added; and administration rate. At least once a shift, note the condition of the IV site and type and size of catheter. Use three separate lines when transcribing orders on the medication administration record. Reserve the first line for the drug name and dose, the second line for the number of tablets or capsules along with the strength of each and the third for administration route, frequency, and additional information. If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. When omitting a medication, document the rationale. For example, “pain medication held pending stabilization of vital signs.” If a medication order is being questioned, tactfully document your conversation with the doctor. If someone else is giving your patient medication while you are off the unit, make sure that person charts the administration.
Avoid verbal and telephone orders when possible, because of the high risk of errors. However, it is not always possible. The proper method for documentation of verbal or telephone orders includes:
Discharge instructions should include: diet, activity, medications (name, reason for taking, dosage, and frequency), skin care hygiene, specific treatments, follow-up appointments, and agency referrals. Along with instructions, document the patient’s and family’s comprehension of the instructions; patient’s ability to demonstrate any procedure taught; and completed transfer forms if appropriate.
The primary purpose of the patient’s medical record is to establish the patient’s health status and need for care, reflect the care given, and demonstrate the results of care itself. It allows for the exchange of information between all members of the healthcare team. The medical record provides legal proof of the type of care the patient received and the patient’s response to that care. Medical records that are poorly maintained, incomplete, inaccurate, illegible, or altered create doubt regarding the treatment given to the patient. Be factual when documenting. Don’t guess, generalize or give personal opinions. Rely on your senses. What did you see, feel, hear or smell. Documentation of patient care holds the healthcare team members to professional accountability.
Chalfee, B. (1995). Patient Care Documentation: Recognizing & Avoiding Legal Disaster, ARC Publishing, Inc. Huntsburg.
DeVore, C. (1999). Documentation: A Nursing Update, Resources for Excellence
Joint Commission on Accreditation of Healthcare Organizations. (2004). 2004 National Patient Safety Goals - FAQs. Retrieved March 15/2004 from http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_faqs.htm#abbreviations.
Joint Commission on Accreditation of Healthcare Organizations. (2004). 2004 Automated CAMH. Oakbrook Terrace, Illinois.
Miller, J. & Glusko, J. (2003). Standing up to the scrutiny of medical malpractice. Nursing Management. 34(10). 20.
Murphy, E. (2003). Charting by exception. AORN Journal. 78(5), 821.
Rodden, C. & Bell, M. (2002). Record keeping: Developing good practice. Nursing Standard. 17(1). 40-43.