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Effective nursing documentation and communication
Seminars in Oneology Nursing, Vol 18, No 2 (May), 2002: pp 121-127
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EFFECTIVE NURSING DOCUMENTATION AND
COMMUNICATION YAN TEYTELMAN O
NE FEBRUARY afternoon several years ago a 15-year-old boy was admitted to the emergeney room of a Massachusetts hospital after three men struck him in the head. The hospital nurse noted that the boy had pain in the right temple area of his head, had been dizzy and vomited prior to arrival, and had a slightly elevated blood pressure. The nurse also took the boy's past medical history, and had made a zero with a diagonal line through it next to the "dotting problems" section in her chart. The nurse then drew an arrow through the symbol and wrote "dotting problems." Three hours after speaking with the nurse regarding the boy, a doctor evaluated the boy, during which time the boy vomited for a second time. After examination, the doctor sent the boy home, with instruetions to eome back to the hospital if vomiting or severe headaehe should occur again. That night, the boy was unresponsive and could not be aroused from sleep. He was transported back to the hospital, and sent for a eomputerized tomography sean, which showed a subdural hematoma. He underwent surgery to alleviate the brain swelling, but eventually ended up with permanent neurologie damage. Apparently, the doctor read the nurse's documentation to mean that the boy did not have a history of clotting disorder; the doctor would not have released the boy from the hospital if he knew about a dotting disorder. Also, during the conversation between the nurse and the doctor, the nurse apparently failed to tell the doctor about the boy's dotting problems. While both the nurse and the doctor denied wrongdoing and blamed negligence on each other, the parties settled the ease for 3.25 million dollars. 1 This ease illustrates the importanee of clear and thorough doe-
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u m e n t a t i o n and eharting on the part of a nurse, as well as the importance of c o m m u n i c a t i o n between the nurse and other hospital personnel. For the nurse, effective d o c u m e n t a t i o n and communication can be the nurse's best friends in his or her professional career. Meeting professional doeum e n t a t i o n and c o m m u n i c a t i o n standards could m e a n not only being competent, but also avoiding a costly and career-jeopardizing malpractice or negligence lawsuit. This article will explore the d o c u m e n t a t i o n and c o m m u n i c a t i o n requirements that an oneology nurse should follow, and will suggest some risk-management practices that a nurse can implement. While for analysis purposes, d o c u m e n t a t i o n and c o m m u n i c a t i o n are broken up into two separate sections, this is not to suggest that the two are not interrelated. In fact, docum e n t a t i o n and c o m m u n i c a t i o n are highly intertwined, and doing one facilitates doing the other. DOCUMENTATION he purpose of d o c u m e n t a t i o n is to promote c o m m u n i c a t i o n among health care providers and to p r o m o t e good care. e Documentation informs other staff about the patient's health status and care provided. Moreover, d o c u m e n t a t i o n is used by the system's risk m a n a g e m e n t departm e n t and quality assurance committees to evaluate patient care and to d e t e r m i n e w h e t h e r improvements should occur, a D o c u m e n t a t i o n is also used by third-party payers to d e t e r m i n e if and when they will pay providers for the care of the patient, by researchers in health care, and for initial and continuing accreditation or licensing grants by health care administrative agencies. Finally, d o c u m e n t a t i o n serves to m e e t legal and professional standards. It is valuable in demonstrating that, within the nurse-patient relationship, the ontology nurse has applied nursing knowledge, skills, and judgment according to professional standards. However, if the nurse has not m e t these standards, this can result in h a r m to the patient because i m p o r t a n t information regarding t r e a t m e n t s and valuable observations can be overlooked. 4 Poor d o c u m e n t a t i o n m a y be used by a patient's attorney in a lawsuit. Nurse-expert witnesses for the patient m a y use poorly kept nurses' notes as support for the conclusion that the patient was poorly m o n i t o r e d by the nursing staff, s A jury may correlate a sloppy, disorganized record with
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sloppy, disorganized care. One study indieates that one in four malpraetiee lawsuits are decided based on the patient's record. 3 In the i n t r o d u c t o r y paragraph example, it has been shown that confusing d o c u m e n t a t i o n can result in trouble. However, lack of d o c u m e n t a t i o n can be just as serious. In one case in Oklahoma, patient A, after undergoing an uncomplicated hysterectomy, was recovering in bed in a semi-private room. Early the n e x t day, patient B from the same room was transferred. However, the nurses from the two shifts failed to d o c u m e n t this transfer. A nursing assistant, mistakenly thinMng that patient B still n e e d e d to be transferred, went to pick her up but only found patient A in the room. Ignoring patient A's protests, the nursing assistant lifted her into a wheel chair, and patient A felt excruciating, cramp-like pain and nearly fainted. Later patient A required additional surgery to repair complications that resulted from lifting her. The nursing assistant never c h e c k e d patient A's identification bracelet or told the nurses about her protests. The court awarded patient A $100,000 in actual damages for pain and suffering and a n o t h e r $5 million in punitive damages (designed to punish for the assistant's reeMess behavior). 6 Therefore, lack of d o c u m e n t a t i o n earl be just as grave, for both the nurse and the patient, as inaccurate or confusing documentation. Nursing is not complete until the care has been properly documented, and the old saying "if it was not documented, it was not done," applies with strong force t o d a y 2 While incomplete or inaeeurate d o c u m e n t a t i o n can be used by a patient's a t t o r n e y in a lawsuit, accurate, complete and legible d o c u m e n t a t i o n can be a nurse's best defense in a potential lawsuit. 7 In one r e c e n t judicial ease, a c a n c e r patient's estate sued the health care staff of a hospital, alleging malpractice in failure to diagnose eolorectal cancer during a h y s t e r e c t o m y . The patient claimed that the patient told the physician she suffered from rectal bleeding, but that the physician did not c h e c k to see if the patient had eoloreetal cancer. The nurses' notes were quite detailed, and they were used during trial to show that the patient did not complain of rectal bleeding or any other symptoms of c a n c e r during the hysterectomy. Based on this, the court found that the hospital staff was not liable, s However, if the nurses had no notes or only sketchy notes, t h e n the jury would have p r e s u m e d against the hospital, and most likely would have found that the staff was guilty.
EFFECTIVE
Therefore, effective d o c u m e n t a t i o n can save the o n t o l o g y nurse a lot of legal trouble. While lawyers can try to make a nurse-defendant look foolish during a testimony, it is difficult to dispute effective documentation. Also, juries tend to believe written d o c u m e n t a t i o n m o r e than oral testimony. Although juries realize that people m a y lie on the witness stand to protect themselves or advance their cause, juries view d o c u m e n t a t i o n written at the time of care more objectively. However, even more significantly, effective documentation can keep a nurse out of the c o u r t r o o m in the first place. 2 Besides the legal issue in keeping effective documentation, there is also the ethical principle of beneficence. Complete and effective recording m a y aid in the cure of the patient's diseases and hasten his/her recovery. On the other hand, incomplete or lack of d o c u m e n t a t i o n m a y be harmful to patient's cure and recovery. 9 Therefore, there is no substitute for accurate and complete documentation. Because of the significance d o c u m e n t a t i o n can play for an oneology nurse, the nurse m a y want to know how to d o c u m e n t properly and what should be included in documentation. From a legal perspective, one should consider how a reasonable nurse would have acted in a similar situation. Any deviation from that standard should be docum e n t e d and explained. Clear d o c u m e n t a t i o n of the variance in the record is more credible than an u n d o c u m e n t e d verbal explanation during a deposition or trial, s According to Koniak-Griffin, 1° the medical record should provide a factual, complete, and objective a c c o u n t of how the nursing process was implemented, including direct and indirect comm u n i c a t i o n among health care professionals. Any generalizations, nurse's opinions, or criticisms of the patient should be left out. 11 The d o c u m e n t a tion should contain (1) an assessment of the client's health status and situation; (2) a care plan or health plan reflecting the needs and goals of the client; (3) nursing actions and the patient's response to the intervention provided; (4) re-evaluation and n e e d e d adjustments to care; and (5) information reported to a physician or other health care provider and that provider's response. To assure that d o c u m e n t a t i o n is accurate, the patient's own description of the problem, and not just the nurse's evaluation of the problem, should be included. In obtaining the description, the nurse should quote the patient w h e n e v e r possible. 12 Also, anything that the nurse teaches the
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patient, such as what steps to take to minimize the risk of being exposed to c a n c e r outside the hospital, should be included in the entry. 11 The patient's n a m e should be recorded on every page of the notes and all d o c u m e n t s must be signed by the nurse with first n a m e or initial, last name, and professional credential. No nurse should docum e n t for a n o t h e r nurse, unless it is a standard practice in a nurse's work setting. However, even when documenting for another, the documenting nurse should accurately reflect who is providing care and who is documenting care, and u n d e r no circumstances should the nurse sign the other nurse's name. The correct time and date should be included for each entry. Any abbreviations used in the record should be restricted to those adopted by the hospital or office where the nurse works. The nurse should not use his or her own abbreviations, however clear or timesaving the nurse thinks they m a y be. 3 Moreover, the e n t r y should be recorded c o n c u r r e n t l y or as close as possible to the time the care was given. 2 In an e m e r g e n c y situation, in which time constraints prohibit the nurse from maintaining a record, an e n t r y should be made soon after the occurrence. Also, when a particular technology or supplies ordered by physician are unavailable, such as, for example, the c h e m o t h e r a p y equipment, the ontology nurse should d o c u m e n t this lack of e q u i p m e n t and relate this to the physician. 10 Even when a physician or a n o t h e r nurse is contacted, that should be r e c o r d e d in a nurse's entry. 3 Doing so m a y help the nurse avoid liability in ease the physician or the other nurse later claims that the nurse was negligent in not contacting him or her when necessary. T h e r e should be no erasures, obliterations, or "whiting out" on any part of the record. If an error in the record must be corrected, it should be done by drawing one line through the error, initialing and dating the line, and documenting the c o r r e c t information next to it. To add information to an already existing entry, the nurse should write the time and date of the addition and indicate that it is being added as an a d d e n d u m to the original entry. 12 However, if a nurse changes the record with intent to deceive, this could have very serious consequences. According to Aiken and Catalano, 9 the "ethical principle of veracity serves as the bedrock issue in documentation." Providing truthful information in the record is quite important. Even if there are o t h e r mitigating circumstances, one piece of falsified d o c u m e n t a t i o n casts
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TABLE
1. ,
Nursing Documentation Do s and Dont s
Do's Make sure the record is the right one before start ng to document Document on appropriate agency forms and clearly identify the patient , Make sure that documentation reflects the nursing process and the nurse s professional capabilities Document from f rst-hand know edge and on y the care persona y performed an except on s an emergency in which one nurse w { be des gnated as a recorder Write legibly in ink Document concurrently or as close as possible to the time the care was given Document in chrono og cal order with the correct time and date for each entry; if an entry is missed document 'lout of order entry" or "late entry" with the date and time of the entry and the time the care was given noting pat ent s response to care Use military time Record the pat ent's name on every page of the notes Use only abbreviations that are on the agency-approved abbreviation list Record any precautions or preventative measures used Record a paiient's refusal tO allow a treatment or take a medication; report this to the supervisor and the patient's physician S gn all entries with f rst n t al, ast name, and title; if using initials the record must have a system to identify the care provider; a line should be drawn from the end of the entry to the nurse s name so that no information can be nserted into the entry Correct errors by draw n g a s ngle line through the error, writing "error" or "mistaken entry' above it or next to it and n t a z ng t; do not use white out, erasers or 'scratch-out' writing Document often enough to tell the whole story Dont's Write imprecise or generalized descriptions; be as specific as possible Give excuses Record what someone other than you and the pat ent sa d, heard, fe t, or sme led unless the information is critica ; in that case, use quotat on marks and attribute the remarks appropriately Record a symptom such as pa n, without also record ng the act on taken to a ev ate the symptom Intentionally alter a pat ent's record; this could result in criminal I abil ty Use shorthand or abbreviations that are not widely accepted Record care ahead of t me; someth ng may happen and you may not actually give the care recorded; recording care that has not been performee is considered fraud
doubt on the entire record, and can easily r e n d e r a malpractice ease indefensible. It can subject the nurse to not only civil (monetary) but also criminal liability. 12 The patient has the right to access his medical record. The Fair Health Information Act of 1997 requires health care providers to allow individuals to examine their medieal records. The Act provides criminal and civil penalties for failure to abide by this requirement. According to Veronesi, 13 patient's access to the medical record can be divided into three parts: the right to access and obtain copies of the record, the right to request correction of information contained in the medical record, and the right to confidentiality. With increasing use of technology, c o m p u t e r recording is becoming a standard practice in
m a n y hospitals and medical offices. C o m p u t e r recording has a n u m b e r of advantages, sueh as more accurate and timely recording, easy access to patient information, more efficient m e t h o d of communicating, and more legible patient information. 9 However, c o m p u t e r recording involves special considerations that a nurse should keep in mind. When using electronic recording, the nurse should never give or share her signature/access codes, never leave patient information displayed on the screen, log off the c o m p u t e r when not using it, and retrieve any printouts immediately2 Thus, as we have seen, complete and accurate d o c u m e n t a t i o n is crucial for a nurse. (For a complete list of Do's and Don'ts in nursing documentation, please see Table 1). However, another significant aspect of the nurse's job is timely and
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thorough communication with the patient and other staff. COMMUNICATION A
eeording to Brent, 3 although it is difficult to say with eertainty that being open and humane toward the patient will avoid a lawsuit, studies indieate that one faetor used to evaluate medical care by patients is their level of satisfaetion with openness and eare by the nurse. On the other hand, indifference to the patient or family, anger experienced by the patient, and poor communication, have all been identified as pivotal factors in the patient's deeision to sue. The importance of eommunieation with the patient cannot be overemphasized. This ineludes, of course, providing medieal information to the patient and family, informing them of changes in care, and edueating them about hospital policies and proeedures. However, on a deeper level, eommunieation includes establishing rapport, practicing "active listening," acknowledging feelings, and responding to the eoneerns of the patient and family. Perhaps the most important aspeet of communication between the nurse and patient involves obtaining and documenting a patient's informed consent to treatment. Informed consent protects the patient's right to self-determination regarding the medical treatment. ~° From a legal and ethieal perspective, informed consent is erueial beeause treating a patient without adequately informing him or her is eonsidered negligence, while treating a patient without his or her consent is classified as battery. ~4 Informed consent should include the patient's right (1) to obtain complete and current information about diagnosis, proposed treatment, and prognosis; (2) to know the risks and benefits of treatment, and any alternative treatments; (3) to receive information in terms the patient earl understand to give informed eonsent before the start of the procedure or treatment; and (4) the right to an interpreter, if necessary. In the ease of a patient who does not speak English, depending on other family members to ensure that the patient understands communication is risky because the language skill level of family members cannot always be assessed. 1° After the patient has been fully briefed and has given informed consent, the patient should sign a consent form. According to
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Sehutte, is a signed eonsent form is most likely to hold up in eourt when supported by doeumentation in the medieal reeord that the physician or nurse personally reviewed the information with the patient before signing. However, like any other good rule, informed consent has eertain exeeptions. The nurse does not need to obtain informed eonsent (1) when there is a life- or limb-threatening emergeney; (2) if diselosing information eould threaten the patient or cause the patient harm or suffering; (3) when the patient chooses not to hear all of the information (in sueh ease, the patient should sign a waiver giving up his or her right to full diselosure); and (4) when the patient has prior knowledge regarding the risks and benefits. 14 Only a eompetent adult ean give consent for himself or herself. If the patient is under 16 years of age (18 in some states), a parent or guardian must generally sign for the patient. To be eonsidered eompetent, a patient must understand the nature and eonsequenees of his or her deeision. Thus, a mentally insane person eannot sign a eonsent form for himself or herself. The flip side of informed eonsent is informed refusal. Every patient has the right to refuse treatment and the right to leave the hospital against medieal adviee at any time and for any reason. 2 If a patient refuses to have a proeedure after being thoroughly briefed regarding the procedure, the patient's refusal and physieal and mental condition should be doeumented, the reasons for refusal should be deseribed, and a refusal form should be si~ned. 14 If a patient refuses to sign, the nurse should doeument what was told and that the patient refused to sign. The nurse or the physician should inform the patient of the risks of leaving without receiving proper treatment. 9 For example, if the patient is undergoing chemotherapy treatment, he or she needs to be fully informed of the eonsequences of stopping ehemotherapy. Also, the patient should be informed that he or she eould eome back for treatment anytime in ease the patient has a ehange of mind. 2 Beyond informed consent and refusal, Brent 3 also advocates a nurse's duty to teaeh the patient not only regarding the risks and benefits of a partieular procedure, but also about a variety of communicable diseases and other health-related information. A good ontology nurse should have the knowledge of not only cancer-related topics and treatments, but also of other common diseases. Transmitting this knowledge to the patient
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is more likely to establish a bond between the nurse and the patient, and more likely to prevent a potential lawsuit. However, on the other hand, the oneology nurse should never tell the patient anything the nurse is not sure about. If a nurse does not know the answer to a patient's question, the nurse should so inform the patient, and should ask the appropriate souree or consult a referenee book. If during t r e a t m e n t something goes wrong, the oneology nurse has a legal and professional duty to immediately notify the patient and the patient's family of what happened. 3 While some m a y view such notification as exposure to liability, not telling the family if something goes wrong could be worse if the incident is later discovered, and eould even subjeet the nurse to eriminal liability. The use of effective c o m m u n i c a t i o n skills with the family is essential. These skills include demonstration of empathy, honesty, and sincere eoneern. Families should be able to express their emotions, including anger and disappointment. ~0 Also, in ease of an incident, the hospital's quality assuranee and risk m a n a g e m e n t team or the nurse's supervisor should be notified immediately, and an incident report should be filed. The report should describe the ineident in n o n a e e u s a t o r y and nonopinionated but r a t h e r factual terms. 3 Besides c o m m u n i c a t i o n with the patient and family, as we have seen from the example in the i n t r o d u c t o r y paragraph, e o m m u n i e a t i o n between the nurse and other staff is just as erueial. In one study, data indieated that hospitals with good lines of c o m m u n i c a t i o n between physicians and nurses had fewer deaths in the intensive care u n i t 2 Not long ago, however, one report identified failure by staff to e o m m u n i e a t e with each other as one of the main problems in e o m m u n i e a t i o n and d o c u m e n t a t i o n of eare. 11 A r e c e n t judicial ease further reinforces the importance of effective and aeeurate e o m m u n i e a t i o n between the nurse and other staff. A w o m a n was admitted to the hospital for thoraseopie biopsy of a right lung mass. After the proeedure, the woman was transported to the recovery area where she complained of some nausea and headache. This p r o m p t e d the physician to prescribe Demerol 75 to 100 mg intramuseularly every 3 hours. However, the nurse apparently misinterpreted the physician's order and administered Demerol 75 mg intravenously, instead of intramuscularly. T w e n t y minutes later the woman was found unresponsive, and all resuscitative el-
forts failed. The court r e t u r n e d a $3.8 million dollar verdict against the nurse. 16 With the rise of technology, oneology nurses are now able to e o m m u n i e a t e with patients and other staff not only in person, but also through telephone, email, and fax. ~rhile these types of eommunieation m a y faeilitate interaction, there are special eoneerns involved with these teehnologie advances. The use of the telephone is a creative alternative to face-to-face interaction, which saves time, contributes to better use of personnel, and has the potential to create greater patient satisfaction with care and to relieve a b a n d o n m e n t fears that m a y be associated with ambulatory eare or early hospital discharge. 17 However, there are special issues involved with telephone usage. Because of a possible bad eonneetion, for example, the nurse m a y misunderstand the patient's description of the problem and the urgency of the situation, or m a y misinterpret a physician's order, espeeially for two drugs that sound similar. ~s According to Scott and Packard, 19 basic eommunieation techniques that are applicable to telep h o n e eare inelude attentiveness, acceptance, empathy, respect, genuineness, self-awareness, and sensitivity to others. Some of the skills that the nurse should use in telephone eare are listening actively for spoken or u n s p o k e n messages, using elear, slow speech at low pitch, speaking clearly and directly into the telephone, eliminating or redueing background noises, and documenting the p h o n e call. In doeumenting the call, the nurse should write down her n a m e and tide, caller's name, time of call, name of the protoeol or referenee used, alternative plan or follow-up, medication review, ehronie diseases, as well as everything that was discussed. 17 Also, the nurse should insist on speaking direedy with the patient, as opposed to a family member, because m u c h important information ean be lost in translation between the patient and the person making the ealt. Another r e e e n d y developed way of communication in the health care field is email. Email proponents uniformly praise electronic c o m m u n i c a t i o n as an efficient means of c o m m u n i c a t i o n that actually deereases time spent answering patient's questions by telephone. Moreover, email allows for more detailed and considerate response to a patient's query than a telephone generally permits. However, the use of email in the medical context not only generates liability eoneerns but also raises serious issues concerning privaey,
EFFECTIVE NURSING DOCUMENTATION & COMMUNICATION
confidentiality, authenticity of authorship, and patient consent. 2° Email, like some other teehnologies, ean be misdirected, printed, intereepted, rerouted, and read by unintended recipients. Patient-related messages and data should generally be proteeted with eneryption software. Such software serambles the message in transit and requires an authentication eode for both transmission and reeeption. Also, to minimize the chance of unauthorized aecess, the nurse should log off from the eomputer after electronieally communicating With a patient. Email should be printed in hard copy and placed into a patient's medieal record. Like with email, there is potential for breaeh of eonfidentiality with materials that are faxed if the fax machine is in an area that is not restrieted to oncology nurse's aeeess. 9 The oneology nurse should follow his or her workplaee's policies and
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procedures regarding the kind and types of information that can be faxed. Information that is too eonfidential, such as a doctor's report regarding whether the patient has eaneer, probably should not be faxed. CONCLUSION
ffective and thorough c o m m u n i c a t i o n and documentation can save the nurse a lot of trouble, for herself, the hospital or office she works for, and also for the patient. Besides being the nurse's best friends in a lawsuit, effective c o m m u n i c a t i o n and documentation can keep the nurse out of the courtroom in the first place. As we move further into the 21st century, with development of new technology, oneology nurses should take special notice of the new ethical, legal, and professional issues that come into being.
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REFERENCES 1. Nurses Service Organization: Nurse's Case of the Month. Available at: http://www.nso.eom/ease/0101.html (accessed Aug 1, 2001) 2. Medwise Consultants: Rx: Lawsuit. Merritt Island, FL, Medwise Consultants, Ine, 2000 3. Brent NJ: Nurses and the Law: A Guide to Principles and Applieations. Philadelphia, PA, Saunders, 2001 4. United Kingdom Central Council for Nursing, Midwifery, and Health Visiting: Standards of Record Keeping. London, UK, UKCC, 1993 5. Brugh LA: Automated clinical pathways in the patient record: Legal implications. Nurs Case Manage 5:131-137, 1998 6. Seribner v HiUerest Medical Center, 866 P 2d 437 (1992) 7, Duffy W: Do not let a deposition ruin your disposition. AORN J 70:34-42, 1999 8. Orloski v McCarthy, 274 AD2d 633, 710 NYS 2d 691 (2000) 9. Aiken TD, Catalano JT: Legal, Ethical, and Political Issues in Nursing. Philadelphia, PA, Davis, 1994 10. Koniak-Griffin D: Strategies for reducing the risk of malpractice litigation in perinatal nursing. J Obstet Gyneeol Neonatal Nurs 28:291-299, 1999 11. Healtheare Risk Management: Proactive risk manage-
ment: Documentation of patient care. Brit J Nurs 7:797-798, 1998 12. Sullivan GH: Keep your eharting on course. RN 63:7579, 2000 13. Veronesi JF: Ethical issues in computerized medieal records. Crit Care Nurs Q 22:75-80, t999 14. Dunn D: Exploring the gray areas of informed consent. Nursing. Available at: http://www.springnet.eom (aeeessed July 25, 2001) 15. Sehutte JE: Preventing Medical Malpractiee Suits. Seattle, WA, Hogrefe & Huber, 1995 16. Porter v S u m m a Health System, 19 no 9 VST 402 (1999) 17. Guy DH: Telephone care for elders: Physical, psychosoeial and legal aspects. J Gerontol Nurs 21:27-34, 1995 18. Kareh AM: What did you say? I can't quite understand your spoken order. Am J Nurs 99:12, 1999 19. Scott MP, Packard KP: Telephone Assessment with Protocols for Nursing Practice. Philadelphia, PA, Saunders, 1990 20. Spielberg, AR: On call and online: Sociohistorieal, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA 280:1353-1359, 1998
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NE FEBRUARY afternoon several years ago a 15-year-old boy was admitted to the emergeney room of a Massachusetts hospital after three men struck him in the head. The hospital nurse noted that the boy had pain in the right temple area of his head, had been dizzy and vomited prior to arrival, and had a slightly elevated blood pressure. The nurse also took the boy's past medical history, and had made a zero with a diagonal line through it next to the "dotting problems" section in her chart. The nurse then drew an arrow through the symbol and wrote "dotting problems." Three hours after speaking with the nurse regarding the boy, a doctor evaluated the boy, during which time the boy vomited for a second time. After examination, the doctor sent the boy home, with instruetions to eome back to the hospital if vomiting or severe headaehe should occur again. That night, the boy was unresponsive and could not be aroused from sleep. He was transported back to the hospital, and sent for a eomputerized tomography sean, which showed a subdural hematoma. He underwent surgery to alleviate the brain swelling, but eventually ended up with permanent neurologie damage. Apparently, the doctor read the nurse's documentation to mean that the boy did not have a history of clotting disorder; the doctor would not have released the boy from the hospital if he knew about a dotting disorder. Also, during the conversation between the nurse and the doctor, the nurse apparently failed to tell the doctor about the boy's dotting problems. While both the nurse and the doctor denied wrongdoing and blamed negligence on each other, the parties settled the ease for 3.25 million dollars. 1 This ease illustrates the importanee of clear and thorough doe-
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u m e n t a t i o n and eharting on the part of a nurse, as well as the importance of c o m m u n i c a t i o n between the nurse and other hospital personnel. For the nurse, effective d o c u m e n t a t i o n and communication can be the nurse's best friends in his or her professional career. Meeting professional doeum e n t a t i o n and c o m m u n i c a t i o n standards could m e a n not only being competent, but also avoiding a costly and career-jeopardizing malpractice or negligence lawsuit. This article will explore the d o c u m e n t a t i o n and c o m m u n i c a t i o n requirements that an oneology nurse should follow, and will suggest some risk-management practices that a nurse can implement. While for analysis purposes, d o c u m e n t a t i o n and c o m m u n i c a t i o n are broken up into two separate sections, this is not to suggest that the two are not interrelated. In fact, docum e n t a t i o n and c o m m u n i c a t i o n are highly intertwined, and doing one facilitates doing the other. DOCUMENTATION he purpose of d o c u m e n t a t i o n is to promote c o m m u n i c a t i o n among health care providers and to p r o m o t e good care. e Documentation informs other staff about the patient's health status and care provided. Moreover, d o c u m e n t a t i o n is used by the system's risk m a n a g e m e n t departm e n t and quality assurance committees to evaluate patient care and to d e t e r m i n e w h e t h e r improvements should occur, a D o c u m e n t a t i o n is also used by third-party payers to d e t e r m i n e if and when they will pay providers for the care of the patient, by researchers in health care, and for initial and continuing accreditation or licensing grants by health care administrative agencies. Finally, d o c u m e n t a t i o n serves to m e e t legal and professional standards. It is valuable in demonstrating that, within the nurse-patient relationship, the ontology nurse has applied nursing knowledge, skills, and judgment according to professional standards. However, if the nurse has not m e t these standards, this can result in h a r m to the patient because i m p o r t a n t information regarding t r e a t m e n t s and valuable observations can be overlooked. 4 Poor d o c u m e n t a t i o n m a y be used by a patient's attorney in a lawsuit. Nurse-expert witnesses for the patient m a y use poorly kept nurses' notes as support for the conclusion that the patient was poorly m o n i t o r e d by the nursing staff, s A jury may correlate a sloppy, disorganized record with
T
sloppy, disorganized care. One study indieates that one in four malpraetiee lawsuits are decided based on the patient's record. 3 In the i n t r o d u c t o r y paragraph example, it has been shown that confusing d o c u m e n t a t i o n can result in trouble. However, lack of d o c u m e n t a t i o n can be just as serious. In one case in Oklahoma, patient A, after undergoing an uncomplicated hysterectomy, was recovering in bed in a semi-private room. Early the n e x t day, patient B from the same room was transferred. However, the nurses from the two shifts failed to d o c u m e n t this transfer. A nursing assistant, mistakenly thinMng that patient B still n e e d e d to be transferred, went to pick her up but only found patient A in the room. Ignoring patient A's protests, the nursing assistant lifted her into a wheel chair, and patient A felt excruciating, cramp-like pain and nearly fainted. Later patient A required additional surgery to repair complications that resulted from lifting her. The nursing assistant never c h e c k e d patient A's identification bracelet or told the nurses about her protests. The court awarded patient A $100,000 in actual damages for pain and suffering and a n o t h e r $5 million in punitive damages (designed to punish for the assistant's reeMess behavior). 6 Therefore, lack of d o c u m e n t a t i o n earl be just as grave, for both the nurse and the patient, as inaccurate or confusing documentation. Nursing is not complete until the care has been properly documented, and the old saying "if it was not documented, it was not done," applies with strong force t o d a y 2 While incomplete or inaeeurate d o c u m e n t a t i o n can be used by a patient's a t t o r n e y in a lawsuit, accurate, complete and legible d o c u m e n t a t i o n can be a nurse's best defense in a potential lawsuit. 7 In one r e c e n t judicial ease, a c a n c e r patient's estate sued the health care staff of a hospital, alleging malpractice in failure to diagnose eolorectal cancer during a h y s t e r e c t o m y . The patient claimed that the patient told the physician she suffered from rectal bleeding, but that the physician did not c h e c k to see if the patient had eoloreetal cancer. The nurses' notes were quite detailed, and they were used during trial to show that the patient did not complain of rectal bleeding or any other symptoms of c a n c e r during the hysterectomy. Based on this, the court found that the hospital staff was not liable, s However, if the nurses had no notes or only sketchy notes, t h e n the jury would have p r e s u m e d against the hospital, and most likely would have found that the staff was guilty.
EFFECTIVE
Therefore, effective d o c u m e n t a t i o n can save the o n t o l o g y nurse a lot of legal trouble. While lawyers can try to make a nurse-defendant look foolish during a testimony, it is difficult to dispute effective documentation. Also, juries tend to believe written d o c u m e n t a t i o n m o r e than oral testimony. Although juries realize that people m a y lie on the witness stand to protect themselves or advance their cause, juries view d o c u m e n t a t i o n written at the time of care more objectively. However, even more significantly, effective documentation can keep a nurse out of the c o u r t r o o m in the first place. 2 Besides the legal issue in keeping effective documentation, there is also the ethical principle of beneficence. Complete and effective recording m a y aid in the cure of the patient's diseases and hasten his/her recovery. On the other hand, incomplete or lack of d o c u m e n t a t i o n m a y be harmful to patient's cure and recovery. 9 Therefore, there is no substitute for accurate and complete documentation. Because of the significance d o c u m e n t a t i o n can play for an oneology nurse, the nurse m a y want to know how to d o c u m e n t properly and what should be included in documentation. From a legal perspective, one should consider how a reasonable nurse would have acted in a similar situation. Any deviation from that standard should be docum e n t e d and explained. Clear d o c u m e n t a t i o n of the variance in the record is more credible than an u n d o c u m e n t e d verbal explanation during a deposition or trial, s According to Koniak-Griffin, 1° the medical record should provide a factual, complete, and objective a c c o u n t of how the nursing process was implemented, including direct and indirect comm u n i c a t i o n among health care professionals. Any generalizations, nurse's opinions, or criticisms of the patient should be left out. 11 The d o c u m e n t a tion should contain (1) an assessment of the client's health status and situation; (2) a care plan or health plan reflecting the needs and goals of the client; (3) nursing actions and the patient's response to the intervention provided; (4) re-evaluation and n e e d e d adjustments to care; and (5) information reported to a physician or other health care provider and that provider's response. To assure that d o c u m e n t a t i o n is accurate, the patient's own description of the problem, and not just the nurse's evaluation of the problem, should be included. In obtaining the description, the nurse should quote the patient w h e n e v e r possible. 12 Also, anything that the nurse teaches the
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patient, such as what steps to take to minimize the risk of being exposed to c a n c e r outside the hospital, should be included in the entry. 11 The patient's n a m e should be recorded on every page of the notes and all d o c u m e n t s must be signed by the nurse with first n a m e or initial, last name, and professional credential. No nurse should docum e n t for a n o t h e r nurse, unless it is a standard practice in a nurse's work setting. However, even when documenting for another, the documenting nurse should accurately reflect who is providing care and who is documenting care, and u n d e r no circumstances should the nurse sign the other nurse's name. The correct time and date should be included for each entry. Any abbreviations used in the record should be restricted to those adopted by the hospital or office where the nurse works. The nurse should not use his or her own abbreviations, however clear or timesaving the nurse thinks they m a y be. 3 Moreover, the e n t r y should be recorded c o n c u r r e n t l y or as close as possible to the time the care was given. 2 In an e m e r g e n c y situation, in which time constraints prohibit the nurse from maintaining a record, an e n t r y should be made soon after the occurrence. Also, when a particular technology or supplies ordered by physician are unavailable, such as, for example, the c h e m o t h e r a p y equipment, the ontology nurse should d o c u m e n t this lack of e q u i p m e n t and relate this to the physician. 10 Even when a physician or a n o t h e r nurse is contacted, that should be r e c o r d e d in a nurse's entry. 3 Doing so m a y help the nurse avoid liability in ease the physician or the other nurse later claims that the nurse was negligent in not contacting him or her when necessary. T h e r e should be no erasures, obliterations, or "whiting out" on any part of the record. If an error in the record must be corrected, it should be done by drawing one line through the error, initialing and dating the line, and documenting the c o r r e c t information next to it. To add information to an already existing entry, the nurse should write the time and date of the addition and indicate that it is being added as an a d d e n d u m to the original entry. 12 However, if a nurse changes the record with intent to deceive, this could have very serious consequences. According to Aiken and Catalano, 9 the "ethical principle of veracity serves as the bedrock issue in documentation." Providing truthful information in the record is quite important. Even if there are o t h e r mitigating circumstances, one piece of falsified d o c u m e n t a t i o n casts
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TABLE
1. ,
Nursing Documentation Do s and Dont s
Do's Make sure the record is the right one before start ng to document Document on appropriate agency forms and clearly identify the patient , Make sure that documentation reflects the nursing process and the nurse s professional capabilities Document from f rst-hand know edge and on y the care persona y performed an except on s an emergency in which one nurse w { be des gnated as a recorder Write legibly in ink Document concurrently or as close as possible to the time the care was given Document in chrono og cal order with the correct time and date for each entry; if an entry is missed document 'lout of order entry" or "late entry" with the date and time of the entry and the time the care was given noting pat ent s response to care Use military time Record the pat ent's name on every page of the notes Use only abbreviations that are on the agency-approved abbreviation list Record any precautions or preventative measures used Record a paiient's refusal tO allow a treatment or take a medication; report this to the supervisor and the patient's physician S gn all entries with f rst n t al, ast name, and title; if using initials the record must have a system to identify the care provider; a line should be drawn from the end of the entry to the nurse s name so that no information can be nserted into the entry Correct errors by draw n g a s ngle line through the error, writing "error" or "mistaken entry' above it or next to it and n t a z ng t; do not use white out, erasers or 'scratch-out' writing Document often enough to tell the whole story Dont's Write imprecise or generalized descriptions; be as specific as possible Give excuses Record what someone other than you and the pat ent sa d, heard, fe t, or sme led unless the information is critica ; in that case, use quotat on marks and attribute the remarks appropriately Record a symptom such as pa n, without also record ng the act on taken to a ev ate the symptom Intentionally alter a pat ent's record; this could result in criminal I abil ty Use shorthand or abbreviations that are not widely accepted Record care ahead of t me; someth ng may happen and you may not actually give the care recorded; recording care that has not been performee is considered fraud
doubt on the entire record, and can easily r e n d e r a malpractice ease indefensible. It can subject the nurse to not only civil (monetary) but also criminal liability. 12 The patient has the right to access his medical record. The Fair Health Information Act of 1997 requires health care providers to allow individuals to examine their medieal records. The Act provides criminal and civil penalties for failure to abide by this requirement. According to Veronesi, 13 patient's access to the medical record can be divided into three parts: the right to access and obtain copies of the record, the right to request correction of information contained in the medical record, and the right to confidentiality. With increasing use of technology, c o m p u t e r recording is becoming a standard practice in
m a n y hospitals and medical offices. C o m p u t e r recording has a n u m b e r of advantages, sueh as more accurate and timely recording, easy access to patient information, more efficient m e t h o d of communicating, and more legible patient information. 9 However, c o m p u t e r recording involves special considerations that a nurse should keep in mind. When using electronic recording, the nurse should never give or share her signature/access codes, never leave patient information displayed on the screen, log off the c o m p u t e r when not using it, and retrieve any printouts immediately2 Thus, as we have seen, complete and accurate d o c u m e n t a t i o n is crucial for a nurse. (For a complete list of Do's and Don'ts in nursing documentation, please see Table 1). However, another significant aspect of the nurse's job is timely and
EFFECTIVE
thorough communication with the patient and other staff. COMMUNICATION A
eeording to Brent, 3 although it is difficult to say with eertainty that being open and humane toward the patient will avoid a lawsuit, studies indieate that one faetor used to evaluate medical care by patients is their level of satisfaetion with openness and eare by the nurse. On the other hand, indifference to the patient or family, anger experienced by the patient, and poor communication, have all been identified as pivotal factors in the patient's deeision to sue. The importance of eommunieation with the patient cannot be overemphasized. This ineludes, of course, providing medieal information to the patient and family, informing them of changes in care, and edueating them about hospital policies and proeedures. However, on a deeper level, eommunieation includes establishing rapport, practicing "active listening," acknowledging feelings, and responding to the eoneerns of the patient and family. Perhaps the most important aspeet of communication between the nurse and patient involves obtaining and documenting a patient's informed consent to treatment. Informed consent protects the patient's right to self-determination regarding the medical treatment. ~° From a legal and ethieal perspective, informed consent is erueial beeause treating a patient without adequately informing him or her is eonsidered negligence, while treating a patient without his or her consent is classified as battery. ~4 Informed consent should include the patient's right (1) to obtain complete and current information about diagnosis, proposed treatment, and prognosis; (2) to know the risks and benefits of treatment, and any alternative treatments; (3) to receive information in terms the patient earl understand to give informed eonsent before the start of the procedure or treatment; and (4) the right to an interpreter, if necessary. In the ease of a patient who does not speak English, depending on other family members to ensure that the patient understands communication is risky because the language skill level of family members cannot always be assessed. 1° After the patient has been fully briefed and has given informed consent, the patient should sign a consent form. According to
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Sehutte, is a signed eonsent form is most likely to hold up in eourt when supported by doeumentation in the medieal reeord that the physician or nurse personally reviewed the information with the patient before signing. However, like any other good rule, informed consent has eertain exeeptions. The nurse does not need to obtain informed eonsent (1) when there is a life- or limb-threatening emergeney; (2) if diselosing information eould threaten the patient or cause the patient harm or suffering; (3) when the patient chooses not to hear all of the information (in sueh ease, the patient should sign a waiver giving up his or her right to full diselosure); and (4) when the patient has prior knowledge regarding the risks and benefits. 14 Only a eompetent adult ean give consent for himself or herself. If the patient is under 16 years of age (18 in some states), a parent or guardian must generally sign for the patient. To be eonsidered eompetent, a patient must understand the nature and eonsequenees of his or her deeision. Thus, a mentally insane person eannot sign a eonsent form for himself or herself. The flip side of informed eonsent is informed refusal. Every patient has the right to refuse treatment and the right to leave the hospital against medieal adviee at any time and for any reason. 2 If a patient refuses to have a proeedure after being thoroughly briefed regarding the procedure, the patient's refusal and physieal and mental condition should be doeumented, the reasons for refusal should be deseribed, and a refusal form should be si~ned. 14 If a patient refuses to sign, the nurse should doeument what was told and that the patient refused to sign. The nurse or the physician should inform the patient of the risks of leaving without receiving proper treatment. 9 For example, if the patient is undergoing chemotherapy treatment, he or she needs to be fully informed of the eonsequences of stopping ehemotherapy. Also, the patient should be informed that he or she eould eome back for treatment anytime in ease the patient has a ehange of mind. 2 Beyond informed consent and refusal, Brent 3 also advocates a nurse's duty to teaeh the patient not only regarding the risks and benefits of a partieular procedure, but also about a variety of communicable diseases and other health-related information. A good ontology nurse should have the knowledge of not only cancer-related topics and treatments, but also of other common diseases. Transmitting this knowledge to the patient
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is more likely to establish a bond between the nurse and the patient, and more likely to prevent a potential lawsuit. However, on the other hand, the oneology nurse should never tell the patient anything the nurse is not sure about. If a nurse does not know the answer to a patient's question, the nurse should so inform the patient, and should ask the appropriate souree or consult a referenee book. If during t r e a t m e n t something goes wrong, the oneology nurse has a legal and professional duty to immediately notify the patient and the patient's family of what happened. 3 While some m a y view such notification as exposure to liability, not telling the family if something goes wrong could be worse if the incident is later discovered, and eould even subjeet the nurse to eriminal liability. The use of effective c o m m u n i c a t i o n skills with the family is essential. These skills include demonstration of empathy, honesty, and sincere eoneern. Families should be able to express their emotions, including anger and disappointment. ~0 Also, in ease of an incident, the hospital's quality assuranee and risk m a n a g e m e n t team or the nurse's supervisor should be notified immediately, and an incident report should be filed. The report should describe the ineident in n o n a e e u s a t o r y and nonopinionated but r a t h e r factual terms. 3 Besides c o m m u n i c a t i o n with the patient and family, as we have seen from the example in the i n t r o d u c t o r y paragraph, e o m m u n i e a t i o n between the nurse and other staff is just as erueial. In one study, data indieated that hospitals with good lines of c o m m u n i c a t i o n between physicians and nurses had fewer deaths in the intensive care u n i t 2 Not long ago, however, one report identified failure by staff to e o m m u n i e a t e with each other as one of the main problems in e o m m u n i e a t i o n and d o c u m e n t a t i o n of eare. 11 A r e c e n t judicial ease further reinforces the importance of effective and aeeurate e o m m u n i e a t i o n between the nurse and other staff. A w o m a n was admitted to the hospital for thoraseopie biopsy of a right lung mass. After the proeedure, the woman was transported to the recovery area where she complained of some nausea and headache. This p r o m p t e d the physician to prescribe Demerol 75 to 100 mg intramuseularly every 3 hours. However, the nurse apparently misinterpreted the physician's order and administered Demerol 75 mg intravenously, instead of intramuscularly. T w e n t y minutes later the woman was found unresponsive, and all resuscitative el-
forts failed. The court r e t u r n e d a $3.8 million dollar verdict against the nurse. 16 With the rise of technology, oneology nurses are now able to e o m m u n i e a t e with patients and other staff not only in person, but also through telephone, email, and fax. ~rhile these types of eommunieation m a y faeilitate interaction, there are special eoneerns involved with these teehnologie advances. The use of the telephone is a creative alternative to face-to-face interaction, which saves time, contributes to better use of personnel, and has the potential to create greater patient satisfaction with care and to relieve a b a n d o n m e n t fears that m a y be associated with ambulatory eare or early hospital discharge. 17 However, there are special issues involved with telephone usage. Because of a possible bad eonneetion, for example, the nurse m a y misunderstand the patient's description of the problem and the urgency of the situation, or m a y misinterpret a physician's order, espeeially for two drugs that sound similar. ~s According to Scott and Packard, 19 basic eommunieation techniques that are applicable to telep h o n e eare inelude attentiveness, acceptance, empathy, respect, genuineness, self-awareness, and sensitivity to others. Some of the skills that the nurse should use in telephone eare are listening actively for spoken or u n s p o k e n messages, using elear, slow speech at low pitch, speaking clearly and directly into the telephone, eliminating or redueing background noises, and documenting the p h o n e call. In doeumenting the call, the nurse should write down her n a m e and tide, caller's name, time of call, name of the protoeol or referenee used, alternative plan or follow-up, medication review, ehronie diseases, as well as everything that was discussed. 17 Also, the nurse should insist on speaking direedy with the patient, as opposed to a family member, because m u c h important information ean be lost in translation between the patient and the person making the ealt. Another r e e e n d y developed way of communication in the health care field is email. Email proponents uniformly praise electronic c o m m u n i c a t i o n as an efficient means of c o m m u n i c a t i o n that actually deereases time spent answering patient's questions by telephone. Moreover, email allows for more detailed and considerate response to a patient's query than a telephone generally permits. However, the use of email in the medical context not only generates liability eoneerns but also raises serious issues concerning privaey,
EFFECTIVE NURSING DOCUMENTATION & COMMUNICATION
confidentiality, authenticity of authorship, and patient consent. 2° Email, like some other teehnologies, ean be misdirected, printed, intereepted, rerouted, and read by unintended recipients. Patient-related messages and data should generally be proteeted with eneryption software. Such software serambles the message in transit and requires an authentication eode for both transmission and reeeption. Also, to minimize the chance of unauthorized aecess, the nurse should log off from the eomputer after electronieally communicating With a patient. Email should be printed in hard copy and placed into a patient's medieal record. Like with email, there is potential for breaeh of eonfidentiality with materials that are faxed if the fax machine is in an area that is not restrieted to oncology nurse's aeeess. 9 The oneology nurse should follow his or her workplaee's policies and
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procedures regarding the kind and types of information that can be faxed. Information that is too eonfidential, such as a doctor's report regarding whether the patient has eaneer, probably should not be faxed. CONCLUSION
ffective and thorough c o m m u n i c a t i o n and documentation can save the nurse a lot of trouble, for herself, the hospital or office she works for, and also for the patient. Besides being the nurse's best friends in a lawsuit, effective c o m m u n i c a t i o n and documentation can keep the nurse out of the courtroom in the first place. As we move further into the 21st century, with development of new technology, oneology nurses should take special notice of the new ethical, legal, and professional issues that come into being.
E
REFERENCES 1. Nurses Service Organization: Nurse's Case of the Month. Available at: http://www.nso.eom/ease/0101.html (accessed Aug 1, 2001) 2. Medwise Consultants: Rx: Lawsuit. Merritt Island, FL, Medwise Consultants, Ine, 2000 3. Brent NJ: Nurses and the Law: A Guide to Principles and Applieations. Philadelphia, PA, Saunders, 2001 4. United Kingdom Central Council for Nursing, Midwifery, and Health Visiting: Standards of Record Keeping. London, UK, UKCC, 1993 5. Brugh LA: Automated clinical pathways in the patient record: Legal implications. Nurs Case Manage 5:131-137, 1998 6. Seribner v HiUerest Medical Center, 866 P 2d 437 (1992) 7, Duffy W: Do not let a deposition ruin your disposition. AORN J 70:34-42, 1999 8. Orloski v McCarthy, 274 AD2d 633, 710 NYS 2d 691 (2000) 9. Aiken TD, Catalano JT: Legal, Ethical, and Political Issues in Nursing. Philadelphia, PA, Davis, 1994 10. Koniak-Griffin D: Strategies for reducing the risk of malpractice litigation in perinatal nursing. J Obstet Gyneeol Neonatal Nurs 28:291-299, 1999 11. Healtheare Risk Management: Proactive risk manage-
ment: Documentation of patient care. Brit J Nurs 7:797-798, 1998 12. Sullivan GH: Keep your eharting on course. RN 63:7579, 2000 13. Veronesi JF: Ethical issues in computerized medieal records. Crit Care Nurs Q 22:75-80, t999 14. Dunn D: Exploring the gray areas of informed consent. Nursing. Available at: http://www.springnet.eom (aeeessed July 25, 2001) 15. Sehutte JE: Preventing Medical Malpractiee Suits. Seattle, WA, Hogrefe & Huber, 1995 16. Porter v S u m m a Health System, 19 no 9 VST 402 (1999) 17. Guy DH: Telephone care for elders: Physical, psychosoeial and legal aspects. J Gerontol Nurs 21:27-34, 1995 18. Kareh AM: What did you say? I can't quite understand your spoken order. Am J Nurs 99:12, 1999 19. Scott MP, Packard KP: Telephone Assessment with Protocols for Nursing Practice. Philadelphia, PA, Saunders, 1990 20. Spielberg, AR: On call and online: Sociohistorieal, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA 280:1353-1359, 1998