The purpose of this course is to refresh healthcare professionals on medical record documentation requirements and professional, responsible documentation strategies.
After completing the course, the learner will be able to:
We live in a measurement culture. Actions, observations and intent are all subject to review and comparison to desired standards. In order to meet pressures internal to our profession, as well as external, records must be generated, stored, and maintained. Medical documentation has become a component of health care as significant as the rendering of hands-on, direct person intervention. Refreshing our knowledge of documentation premise and process is essential to hone our professional technical skills.
Medical documentation refers to any written or electronically generated information about a client describing services or care provided to that client. Documentation may be in the form of paper records or electronic documents. Electronic documents include computer-created medical record files, faxes, e-mails, pictures, video or audio recordings. Through documentation key observations, decisions, actions, and outcomes can be communicated, as well as preserved in a lasting fashion. The intent of documentation is the creation of a permanent, accurate account of what occurred and when it occurred.
The challenge today is to provide succinct but comprehensive records that accurately portray the client'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 contributed to client outcome.
With the abundance of information sources present in health care’s data-rich environment, a definition of exactly what elements comprise the legal health record is important. Guidelines from AHIMA, the American Health Information Management Association, suggest that each organization be responsible to define the content of the legal health record in accordance with its system capabilities and legal environment.1
Each health care facility must have a compliance system able to guide and ensure an accurate and complete record generation (e.g. documentation), record maintenance, and records destruction (when appropriate). The American Health Care Association (AHCA) offers guidance to facilities in the design of compliance programs. In their recommendations concerning the creation and retention of records, AHCA and AHIMA list the need for each facility rendering health care to address the following items.2
Legal health records must meet accepted standards present within each organization as well as those applied by review or oversight authorities such as the Centers for Medicare and Medicaid Services, state and federal regulations, or the Joint Commission on Accreditation of Healthcare Organizations.
While organizations such as the Joint Commission recognize that both physical (e.g., paper charts) and electronic health records must be individualized to the unique needs and settings of each care facility some basic components should uniformly be present1:
Documentation in the client chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observes as well as how we respond with interventions, or the formations of plans of care, are entered into this repository of information centered upon the client.
Health care facilities are tasked by organizations such as The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS) to effectively manage the collection of health information using uniform data sets and policies that guide record creation and handling. While the components of the health record may differ somewhat in each facility, certain minimum standards are expected for both paper and electronic documentation systems.3
Suggestions from external sources can be very specific, such as the 2018 abbreviation use standard (IM.02.02.01.EP.02 & 03) from the Joint Commission. In this standard, (formerly known as NPSG.02.02.01), each hospital is required to have a written policy that addresses the use of abbreviations and symbols. This policy is to address all orders and medication-related documentation that are handwritten (including free-text computer entry) or pre-printed forms.4
The Joint Commission Information Management Chapter,
2018 Accreditation Standards: Hospital,
Standard IM.02.02.01.EP.02 & 03
“Do Not Use” List4
Each hospital is to have a written policy that includes the following:
The knowledgebase offered within the profession of nursing is full of practical bits of help. Allied health professions such medical information management specialists can provide insight into how documentation is perceived and what is and is not the best phrasing. Common practice experience leads to acceptable manners for handling and conveying of information clearly and consistently.5
Progress notes are essential medical records based on the healthcare profession process: assessment, professional diagnosis, planning with goal setting, implementation/ interventions, and evaluation. Progress notes serve to;
Each care setting tends to specify the patient data format or chart note style that they prefer for progress notes. Follow your facility’s documentation policies. There are many charting styles currently available. Each notation format has advantages as well as disadvantages. Some have been around for a long time, while others are rather new. Many institutions blend format systems together to get just the right record-keeping style that works for their unique needs. Whichever style is used, clearly communicate while avoiding potential legal problems. Careful forethought and practice using a charting strategy will lead to consistently clear and legally defensible documentation.
The narrative note is the most traditional medical record progress note style. It involves the documentation of assessment data, interventions made, and patient responses in chronological order with free-flowing structure, content and form. Many facilities rely solely on this format, while in other settings narrative notes serve to supplement check-off forms and flow sheets.
Narrative charting tends to be thorough and detailed. It is also time-consuming. The narrative chronological format is popular with healthcare professionals who document complex descriptions with comprehensive assessments.
One critical legal issue with this style is that shift to shift, person to person, 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 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 may be made regarding the "professionalism" of the nurse and the facility.
To avoid problems, make sure that each nurse tries to achieve a measure of consistency with record keeping. Perhaps decisions can be made regarding the placement of vital signs, patient outcomes and care rendered within each narrative paragraph turning critical thinking into critical charting.8 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 that information in the narrative unless there is a specific change that you are addressing in the note.
Problem area charting formats focus on specific needs rather than general assessment information.9 POMR or problem-oriented medical record systems frequently use acronyms to provide memory aides as to the structure of the progress note being written. As POMR documentation focuses on progress in specific problem areas, it is sometimes generically referred to as “focus charting.10”
Some problem-oriented charting acronyms:
We will now look at examples of POMR format charting as they move along a continuum away from straight narrative documentation.
SOAP charting follows a distinct format that defines the various sources of information followed by a plan of intervention. SOAP stands for subjective, objective, assessment, and plan.
The basic SOAP format for progress notes are sometimes expanded to fit unique organizational needs, such as;
DARP moves further along the continuum away from straight narrative-chronological charting into a combination of check-off forms and flow sheets supplemented with narrative progress notes. The POMR style progress note most often follows the DAR(P) format;
Risk management strategies with this charting style need to make certain that healthcare professionals from the unit where the forms will be utilized have input into design of the check-off forms and flowsheets. Ample room must be present to record pertinent information. Each institution should provide the staff with sufficient training to utilize the strengths of this system to its best advantage.
Many consider charting by exception (CBE) the antithesis to narrative progress notes. CBE is a format developed to overcome the recurring frustration of lengthy, repetitive narratives. It consists of a heavy component of flowsheet documentation with a blending of POMR narrative added. Quickly marked checklists and flowsheets document normal assessment findings and routine care with narrative documentation limited to findings outside the expected norm.11
One strong advantage is that flowsheet design can incorporate clearly defined expectations for the type of patients cared for on each unit and in each care setting. Standardization of forms process within each facility allows caregivers to provide consistency in patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by interventions provided. Charting by exception can reduce the amount of time spent on documentation.
Charting by exception has the potential to be a great asset to electronic medical records documentation. The use of quickly scored checklists that document routine matters complements at-the-bedside computerized data entry. By shifting the emphasis from descriptive discursive narrative paragraphs for every routine and expected event, to minimal narrative notes for only unexpected or highly significant events CBE may be the cutting edge of medical documentation.11
Since charting by exception is a departure from more traditional medical documentation models, it can lead to legal challenge. 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 may not be a component on a patient problem checklist, preventing full credit for the work done.
Let the Lawyers Speak…12,13
“If it wasn’t Charted, it wasn’t Done” is inaccurate and misleading,
According to Dan Small of the legal firm Holland & Knight and Launa Rutherford of the firm Grower, Ketcham, Rutherford, Bronsor, Eide & Telan.
Proper documentation is important, they continue, but documentation is not care. “Nothing in the law requires health professionals to document everything they do or say. That would be impossible.”
Charting should be “a way of trying to record things that give a fuller picture of the care,” along with specific key elements essential for documentation.
Clinical pathways (aka care pathways, critical pathways, care maps, or integrated care pathways) are multidisciplinary descriptions of the expected care for a specific illness or condition with a specified timeline that is the anticipated length of stay. Pathway focus is on outcomes and efficient use of resources while still providing quality care. Pathways have proven to be a good way to identify variances from expected outcomes and promote efficiently organized care, centered on evidence-based practice.
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 testing, patient and family education, and outcomes. Some facilities are using clinical pathways in conjunction with charting by exception. Use of pathways is changing documentation in many healthcare settings. Managed care, for example, is heavily invested in clinical pathways, recognizing them as an important tool for rendering and documenting quality care.
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 and progress notes with documentation made directly onto the pathway document unless the patient does not meet the outcome. At this point, a narrative note is made.
Software programs are available 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 healthcare professional to select pre-written phrases to describe the patient's condition with very little sentence formation performed by the professional.
Fear Factor in Computerized Health Record Technology 14
Concerns about electronic medical health records in discussions among healthcare professionals often focus more on the mechanics of the system, its availability and security, rather than on documentation format styles. At heart, fears tend to revolve around three main points commonly cited as confidentiality, integrity and availability. Often referred to as the “CIA” properties of computer documentation;
Distrust regarding computerized health records is a factor that limits acceptance with the staff asked to utilize them. The use of consistent measurable security processes and education concerning the systems employed can help overcome the fear of computerized charting and documentation.
Ample education must be provided before implementing a computerized system. A "hard copy" of essential information should be printed at designated times to ensure an accurate record in case of computer problems, as determined by each facility’s policy. Error correction must be completed before the information is permanently stored, and all information should be double-checked before you enter it. Any corrections made after storage will have to be specially noted.
Remember the basics of HIPAA training related to the use of electronic medical documentation.
Certain guidelines apply regardless of the documentation format you use. 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 handwriting or their intent. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial, not only for safe patient care but also because they enhance your professionalism. Make sure a dictionary is kept available to anyone responsible for charting and post a list of commonly misspelled words. Avoid abbreviations when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART before you begin writing.
The medical record is a permanent legal "business record," and as such, entries must not be made in pencil or erasable ink. Write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest 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 "gray out" any writing covered by highlighter.
If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.), use double-sided tape or tape only onto blank paper. Even though the tape itself is clear and can be read through by the naked eye, a copy machine may "blackout" 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 your name, followed by your professional designation.
When adding a progress note, follow institutional policy to determine if you are to note the 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 gives the impression of vagueness. Note exact times of all critical treatments, physician contact, or notices to supervisors. 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, The Joint Commission requires that the initial assessment and care plan to be performed and documented by a registered nurse. Documentation by the proper person is especially important in educational, nutritional and rehab assessments.
Avoid documentation practices that either 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 any remaining blank space on the line before signing your name. Do not 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 when caring for a patient.
To correct entries, put a single line through the error then 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 your 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 you can 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 the 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 misunderstanding12:
Never chart for someone else. If you did not participate in an activity or observe someone else’s care, do not 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. Only countersign notes when required by the institution.
Keep documentation objective. Do not chart opinions or assumptions. Rather than writing, "the patient was unresponsive,” your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid 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 — instead, note observations as a description of the behaviors.
Unusual occurrences and patient injuries need documenting. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Document comments from the patient, roommate or visitor clearly using quotation marks. 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 document a client’s uncooperative behavior. For example;
Document any safeguards or other preventive measures you are taking to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
Chart that the facility’s safekeeping for valuable possessions system was explained and made available to the patient. Encourage patient/family to have possessions 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 the safe are recorded on a receipt complete with the client’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. Frequently update the list of valuables for long-term patients. Before a patient is transferred, take an inventory of the list of valuables to verify location of items.
Document medication administration in as thorough a manner as possible. Note the date, time, your initials, the method of administration, and the site where the medication was given if it is an injection. When recording intravenous (IV) infusions note the site of infusion, type and amount of fluid, medications added, and the administration rate. At least once a shift, note the condition of the IV site along with the type and size of catheter. 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 that they administered the medication.
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:
Read-Back Rule 15
Documentation of telephone orders, verbal orders, and the reporting of critical test results by either voice or phone fall under The Joint Commission’s “Read-Back” requirement.
Clarity and confirmation that the receiving person has received and written exactly what was intended is the purpose of read-back. Implementation is exactly how it sounds. Read back the order and get confirmation from the person who gave the order.
Documentation that read-back has occurred should follow the policy set by your facility. In general, the notation T.O./R.B. and your signature are acceptable, although your place of employment may require that “telephone order read back” or “verbal order read back” be written out.
Documentation of discharge instructions should include information related to diet, activity, medications (name, reason for taking, dosage and frequency), skincare hygiene, specific treatments, follow-up appointments, and any agency referrals. Along with the note relating that instructions were given, document the patient and family’s comprehension of the discharge instructions. If any skills were demonstrated, record the patient’s ability to demonstrate in return what was taught.
Situation: At 2:00 am, on night shift rounds, nurse Sally Rise LPN notices client being treated for a UTI and chronic liver disease with a bloody area on her bed linen from her left forearm where a heparin lock had been placed for IV antibiotics. The client, 62-year-old Rehma Fitzgerald, rouses easily and is aware of where she is. She states being itchy and must have scratched it out.
8/1/2019 0200 Ms. Fitzgerald states, “Oh dear, I must have pulled that fluid tube device out when I was scratching. I have been so itchy!” Six cm area of damp blood present on bed covers beside clients left forearm. Left forearm heparin lock found pulled out of skin, dangling from opsite dressing remnants. No visible hematoma. Client pulled heparin lock out unintentionally due to skin irritation at site. Pressure held at bleeding site for three minutes to assure clotting. Site cleansed with betadine swipe and band-aide applied. Linen changed. IV team will be contacted to resume IV access. Note will be left for physician informing her of incident and requesting prn anti-itch medication. -------------------- S. Rise LPN
8/1/2019 0200 L. forearm heparin lock found DC’d by client. No visible hematoma. 6cm damp blood drainage on bed linen. Client states had been itching and must have scratched device out. Site cleaned; pressure held 3min. Light dressing applied. IV team and MD to be informed. Anti-itch prn will be requested. Client states “Thank you, dear. I must have scratched that device out. I have been so itchy!” ----- S. Rise LPN
The primary purpose of medical documentation is to establish that individual’s health status and need for care, record the care given, and demonstrate the results of the care. Medical documentation allows for the exchange of information between all members of the healthcare team. The health record provides legal proof of the type of care the patient received and that person’s response to that care. Medical documentation that is poorly maintained, incomplete, inaccurate, illegible, or altered, generates doubt regarding the treatment given to the patient. Be factual when documenting. Do not guess, generalize, or give personal opinions. Rely on your professional guided physical observations. What did you see, feel, hear or smell? Documentation of patient care holds the healthcare team members to professional accountability and demonstrates the quality care you have given.