- Email: [email protected]
Examining Board Discipline of Nurse Practitioners for Medical Records Infractions
The Journal for Nurse Practitioners 15 (2019) 613e617
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Continuing Education
Examining Board Discipline of Nurse Practitioners for Medical Records Infractions Omobola Awosika Oyeleye, EdD, JD a b s t r a c t Keywords: board of nursing discipline documentation medical records nurse practitioner sanctions
This study reviews the records of nurse practitioners (NPs) who were disciplined in Texas by the Board of Nursing between 2015 through 2017, specifically those who were disciplined for documentation-related infractions. The specific details of the infractions are discussed, such as failing to document clinical events that occurred and falsely documenting events that did not occur. Wherever the NPs provided a reason or rationale for their actions, those are also discussed, as are the specific sanctions handed down by the Texas Board of Nursing in each case. Implications for practice and principles that could assist NPs to prevent such infractions are also enumerated. © 2019 Elsevier Inc. All rights reserved.
This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their increased compliance with documentation requirements for their roles, as measured by a score of at least 70% on the CE evaluation quiz. At the conclusion of this activity, the participant will be able to: A. Identify appropriate documentation and its importance B. Evaluate documentation practices that receive board sanctions C. Explain the types of sanctions that can accompany board discipline The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDAapproved recommendations for treatment. This activity has been awarded 1 Contact Hours of which 0 credit are in the area of Pharmacology. The activity is valid for CE credit until November 1, 2021. To receive CE credit, read the article and pass the CE test online at www.npjournal.org/cme/home for a $5 fee.
Introduction Health care documentation is a written or electronic record of the health status of a client. It also contains the care provided to the patient. Documentation of care is the nurse practitioner’s (NP’s) https://doi.org/10.1016/j.nurpra.2019.06.009 1555-4155/© 2019 Elsevier Inc. All rights reserved.
professional responsibility, and it ensures continuity of appropriate care.1 Documentation is expected to be accurate, complete, legible, accessible, and timely. It is a vital medium of communication within a healthcare team. Inaccurate or incomplete documentation can have catastrophic consequences in the nursing environment.2 This analysis of disciplinary actions by the Texas Board of Nursing reveals the documentation-related errors made and the ensuing consequences.3
Background Medical records are a significant part of any health-related practice. They are the depository of information about patients’ medical and health experiences and the basis of health care decisions and research. Because of their significance, they must be complete, accurate, and created in a timely manner. Therefore, the integrity of the information shared among health care professionals for care and research depends on the accuracy of health care records.2,4 This study reviews the errors made by NPs in relation to documentation and reveals the frequency of these errors and their specific types. The reasons given for the errors, where possible, and the sanctions meted out by the Texas Board of Nursing are enlightening. There is a dearth of studies that investigate board actions against advanced practice registered nurses (APRNs) for medical records error. A study by Hudspeth (2007) analyzed the reports of APRN disciplinary actions by 38 boards of nursing in the United States in 2003e2004 and found that most APRNs experienced board sanctions in the areas of chemical impairment, exceeding scope of practice, unprofessional conduct, and safety or abuse of patients. Altogether, there were 688 reported cases in a total of 125,882 APRNs, representing approximately 0.55%.3,5 Another
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O.A. Oyeleye / The Journal for Nurse Practitioners 15 (2019) 613e617
Table Texas Nurse Practitioner Medical Records Disciplinary Data from 2015 to 2017
2015 2016 2017
Approximate No. of NPs
No. of NPs Disciplined Records Reviewed
Total No. NPs Disciplined Medical Records-Related Errors
Total No. Medical Records-Related Infractions
14,825 21,972 24,105
36 49 33
1 10 4
1 11 4
Data from records reviewed from 2015 through 2017. NP ¼ nurse practitioner.
study that investigated 21 case studies of nursing errors from 9 state boards of nursing disciplinary action against registered nurses (not APRNs) found 8 categories of errors, including documentation errors.1 Other articles only inform APRNs about the board disciplinary process4e7 or encourage emergency department NPs to be cognizant of their state’s Nurse Practice Act and the potential for board disciplinary action.8 Purpose This study is aimed at examining the medical record practices of NPs for which they were disciplined by the Texas Board of Nursing, with a view to enlightening NPs about such practices and, ideally, preventing them. Where the NPs provided any type of defense or reason for their actions, those are also discussed. If the public cannot trust the accuracy of patients’ medical records or if health care professionals are unable to confidently base their treatment plans on their patients’ medical records, it could lead to unnecessary tests and hamper the efficiency of the care provided and may jeopardize the patient’s health and life. Methods The Texas Board of Nursing maintains a record of disciplinary actions against Texas nurses on its website. These records are published 4 times a year, in January, April, July, and October and include all the details and board proceedings surrounding each case. The records included in this study are limited to the cases that were decided between January 1, 2015, and December 31, 2017, being the last 3 years for which complete records were available at the time of this writing. Because the publication dates on the website are often many months after the decision dates, the records reviewed in this study were those published between April 2015 and April 2018. Each publication month link was viewed, and the cases with links indicating that they were held by advanced practice nurses were opened, read, and sorted by the specific infractions. In many cases, the nurses committed more than 1 infraction, but only the ones relating to documentation were selected for this study. A second review was done to determine the specific cases where the APRNs were NPs, as opposed to being nurse anesthetists, certified midwives, or clinical nurse specialists. Once the NP cases were identified, they were reviewed and sorted by the NP’s specific errors to determine the themes that existed. In many cases, there was only 1 nurse engaging in 1 type of infraction. In a few cases, 2 or more nurses engaged in the same type of infraction, such as in cases where the NPs prescribed opioids without documentation of appropriate assessment and rationales. In such cases, the nurses’ actions were discussed under their common infraction. Sixteen cases met the specifications. Findings The number of NPs cited in the study for each year represent unduplicated NPs in September of each of the relevant years. Texas
in 2015,9 2016,10 and 2017.11 1n 2015, 68 APRNs received board discipline. Twenty of them were not NPs, and the records for 15 individuals were not available on the website. Therefore, they were not included in the study. In 2016, 68 APRNs were disciplined. Eleven of them were not NPs, and the records for 8 individuals were not available on the website, so they were not included in the study. In 2017, 65 APRNs received board discipline. Six of them were not NPs, and the records for 10 individuals were not available on the website and were not included in the study. The Texas Board of Nursing records from 2015 through 2017 were reviewed specifically for instances in which the NPs were sanctioned by the board for acts that constituted inaccurate or inappropriate medical records documentation. The instances discussed here are not per person but by incident. For example, if 1 NP is sanctioned for more than 1 incident relating to inaccurate/ incomplete medical records, each infraction is counted as a separate one. Therefore, the number of infractions may be higher than the number of NPs sanctioned (see Table). Note that in this article, fictitious initials have been used to describe each NP. The most frequently cited reason for disciplinary action was unprofessional conduct. The 2 most common was conduct that was “likely to deceive, defraud, or injure a patient or the public”12 and “failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board’s opinion, exposes a patient or other person unnecessarily to risk of harm.”13 The specific cases were about failure to conform to standards of nursing practice relating the Nursing Practice Act, the board’s rules, and local, state, and federal laws; failure to implement measures that promote a safe environment; failure to report and document in an accurate and complete manner; and failure to comply with the authorization granted for practice in an advanced practice role.14 Other violations were about unprofessional conduct relating to unsafe practices that demonstrate the individual carelessly and repeatedly demonstrated that he or she is unable to abide by the minimum acceptable standards of nursing practice, failure to abide by standards of one’s particular areas of practice, and failing to manage patients’ records appropriatelydconduct that is dangerous to a patient, falsifying records, and false, deceptive, or misleading information related to one’s nursing credentials.15 An analysis of all the cases revealed that the cases fell into 2 major categories: Failure to record an event or activity that occurred and affirmatively recording a clinical event or activity that did not occur. Each category includes cases of different NPs sanctioned for different specific infractions. Those cases are discussed next. Failure to Document an Assessment or an Event That Occurred or Should Have Occurred Some of the infractions to be discussed in this section are related to failure to document assessments, failure to document orders, failure to sign patient records, and failure to document clinical rationale.
O.A. Oyeleye / The Journal for Nurse Practitioners 15 (2019) 613e617
615
Failure to Document Assessments
Failure to Document Own Verbal Order
There were 4 cases in which assessments were lacking, and the NPs prescribed a mix of medications such as hydrocodone, Soma, and/or alprazolam (Xanax), all of the same strength, dose, and quantity, to the same patients. These types of prescriptions, known as “cocktails,” were repeatedly handed out without completely or accurately conducting any appropriate assessment/evaluation or individualized treatment plans. There were no signed informed consent or treatment of chronic pain agreements. There was no documentation of periodic reviews of the patients’ treatment or medical justification for the controlled substances that were prescribed. There was also no documentation of any collaboration with a delegating physician or any measures to monitor the patients for signs of whether they were engaging in drug-seeking or any other abusive behavior. In all 4 cases, there were multiple patients involved, and the NPs did not offer any defense for their actions. In some of the cases, the NPs were sanctioned by limiting their prescriptive privileges for controlled substances, requesting them to surrender all US Drug Enforcement Administration Controlled Substances Registration Certificate and Texas Department of Public Safety Controlled Substances Registration Certificate, where applicable. In 1 of the cases, the NP was sanctioned with a stayed suspension and a 2-year probation. In another case, the NP voluntarily surrendered her license, including controlled substance privileges, and her Texas Department of Public Safety Controlled Substances Registration Number was revoked.
In a case of failure to document a verbal order, O.P., an FNP, had a patient whose international normalized ratio was elevated. During consultation, she instructed the patient to reduce the dosage of Warfarin being taken. However, she made no record of the instruction she had given the patient or the new dosage. The board deemed the inaccurate medical record could potentially injure the patient because other providers would base the patient’s treatment on the incomplete and inaccurate information in the patient’s medical records. In response to the board, O.P. stated that she had relayed the specific instructions to her nurse and that she believed it was the nurse’s responsibility to record it. The board sanctioned her by giving her a warning with stipulations, at which time she asked that her license be placed on inactive status. To reactivate her license in future, she would have to meet all the conditions and stipulations placed on her license.
Failure to Document a Patient’s Clinic Visit A family NP (FNP), T.L., faced disciplinary action because she submitted a bill for the care of a patient. However, the patient had not visited the clinic for any nursing services. In her defense, T.L. claimed that her stepmother was the patient and that she had been a patient for years. However, because the stepmother lived at a distance had only been to the clinic for her first visit. She claimed that subsequent visits, although they took place in her stepmother’s home, had been described as “clinic visits” because she had been using the clinic’s resources. She was sanction with a Warning With Stipulations. The stipulations were not spelled out because T.L. opted to put her license on inactive status. If she ever decided to reactivate her license in future, then the stipulations would be applied at that time.
Failure to Document Rationale for Clinical Decision In another case where there was a lack of documentation of an assessment, S.V., an FNP, worked in a correctional institution. An inmate had initially been granted a “lower-bunk status” by S.V. A lower-bunk status is an order stating that, for clinical reasons, an inmate should only be apportioned a lower bunk and not an upper bunk in the cell. Soon after, S.V. revoked the lower-bunk status without documenting the assessment that led to the revocation. In her defense, S.V. stated that the lower-bunk status had been granted after a review of the inmate’s medical history and a documented physical assessment. However, after the new status had been granted, the inmate’s custody officer informed her that the inmate had been acting and had put on an “Oscar-worthy” performance. This caused S.V. to reevaluate her assessment and to conclude that the result of the assessment was based on deceit. She therefore revoked the inmate’s lower-bunk status and did not document the latter event. She was sanctioned to undergo remedial education.
Failure to Document Discussion With Other Health Care Providers Unlike the previous case in which the NP was disciplined for not recording her instructions to a patient, E.Z., the NP in this case, was sanctioned for, among other things, not documenting her discussion with a registered nurse in the care of a patient. She had received a phone call from the nurses regarding the care of a pediatric patient. E.Z. gave orders to the nurses about actions she wanted them to take and the information to be given to the patient’s mother. However, there was subsequently no documentation in the patient’s medical record that indicated that there had been any telephone discussion with the nurses regarding the patient’s care, nor was there a record of the instructions she gave them. In her defense, the E.Z. stated that she thought the patient was about to be discharged, and she had told the nurses to give some information to the patient so that the patient could share it with her primary care provider. She found out later that the patient had not been discharged. The Board sanctioned her with a warning with stipulations. The stipulations included remedial education. Failure to Sign Patients’ Visit Notes in a Timely Manner Delay in signing was the reason for sanctions against the NP in this case, which indicates that it is not enough to document encounters with patients; it is equally important to complete and sign the documentation in a timely manner. Among many other allegations, V.M. failed to sign numerous patients’ electronic test results and visit notes. There was no indication given regarding how much time had lapsed, but judging by V.M.’s response, it was enough time for the events to have faded from her memory. In her response, V.M. stated that she did not recall the details of those events but that she believed any abnormal results that occurred would have been minute and her facility would always order repeat testing before alerting the primary care providers. The board sanctioned her with a warning with stipulations. The stipulations included remedial education. In another case in which test results were not documented, M.M., an FNP, failed to document, among other things, the results of a rapid strep test and a patient’s past surgical history. M.M.’s response indicated that things moved very fast because the patient fainted during medication administration and while she was charting. Therefore, she did not have time to document those findings. She received a sanction of remedial education and a $500 fine.
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Documenting Activities or Events That Did Not Occur This section describes instances in which assessments were documented although they had not been done or had not been done in the way reported, documenting tests and surgical preparation that had not been done, and signing off on the erroneous action of another caregiver. Documenting Assessments that Were not Done Although some NPs failed to document the assessments that they did, others created inaccurate records by recording assessments that had not been done. A family nurse practitioner, M.J., was sanctioned by the board for documenting patient assessments that had not actually been conducted. The 2 patients involved had not been examined, nor were their vital signs taken. Yet assessment documentation, including vital signs, were recorded. M.J. denied having any fraudulent intent but admitted that she had indeed not assessed 1 of the patients. She stated that this error occurred because she was in a hurry while documenting in the electronic health records. This caused her to input cardiovascular and respiratory data that she had not intended to record. Regarding the second patient, M.J. stated that she had erroneously recorded the information of 1 patient into the record of another patient who had a similar diagnosis. The board sanctioned her with a warning with stipulations. The stipulations included remedial education. In a slightly different twist in which an NP inaccurately documented an event of one kind as another kind that did not occur, family NP S.T. had performed only phone assessments of 3 patients. However, she documented that full physical assessments were conducted, including vital signs. In addition, she indicated in the patients’ medical records that the assessments were conducted in the patients’ homes, even though she had not conducted any home visits. S.T. admitted that only phone assessments were performed because the conditions of the road on those days prevented her from reaching the patients and that the facility allowed phone interviews in lieu of a physical visit if the nurse had an emergency that prevented a physical visit and claimed that she obtained previous assessment evaluation data from the primary care physician. S.T. received a reprimand with a $250 fine. In another case in which an NP documented an assessment that had not been done, G.M., a family NP, documented that she had begun a patient’s history and physical (H&P) at a particular time, although she did not arrive in the building until more than 30 minutes later. She also documented that she began 2 other patients’ H&P at another time, although the patients were not admitted until more than 1 hour after the stated times. G.M. responded that she had erroneously entered the wrong times in the logs. In another allegation against G.M., she had documented that a patient refused an H&P. However, the patient denied that she had seen or spoken to G.M. and that she had refused an H&P. In her response, G.M. stated that she charted this because she had received information from a registered nurse that the patient did not want to see her. She received a warning and a $1,000 fine to be paid within 90 days. Documenting Tests That Had Not Been Done In another case in which a patient’s medical record included an event that did not occur, F.C., a family NP, documented in a patient’s record that an x-ray had been performed. However, it was discovered that the patient had not received an x-ray. Rather, another
patient had received an x-ray, but it was not the patient in whose records F.C. had entered it. Her response did not include an explanation for what led to the error. She was sanctioned to receive remedial education. Signing Off on the Erroneous Action of Another Caregiver In this case relating to an error in documenting in a patient’s electronic medical record, a medical assistant had administered a vaccine to a 5-month-old patient even though the vaccine was not approved for children under 4 years old. C.S., an FNP, signed the progress notes, without recognizing the error made by the medical assistant. This was not discovered until 8 months later by another provider, who wanted to revaccinate the patient. C.S. admitted that she did not notice the medical assistant’s notes or that the vaccine was wrongly administered. However, once it was discovered, she stated that she took steps to remediate and was informed by the manufacturer that the patient did not need to be revaccinated. She received a sanction of a warning with stipulations. The stipulations included remedial education and a limitation on her license that prevented her from working outside the state of Texas in a nurse licensure compact state without obtaining permission from the Texas Board of Nurses and the board of the other state. Conclusion As has been demonstrated in other studies, most nurses are lawabiding and manage to avoid infractions that place them before the board of nursing. The percentage of nurses in Texas who faced board disciplinary action in the years studied was less than 1%. This figure is in alignment with previous data.5 In addition, contrary to many anecdotal reports that threaten nurses and nursing students about “losing their license,” the results in this study seem to indicate that most nurses who come before the board do not commit offenses that warrant getting their licenses revoked. There are consequences that range from a warning up to a license revocation. However, a revocation was not common. Rather, the board considers each situation on a case-by-case basis.16 Although some infractions received serious sanctions and others received light ones, every person who received a sanction of any kind also was required to take remedial classes. The remedial classes generally included a course in Texas nursing jurisprudence and ethics and a course by the National Council of State Boards of Nursing called “Sharpening Critical Thinking Skills.” Other courses may be prescribed, depending on the specific offense. It is important to remember that documentation errors endanger patients in that subsequent providers will rely on either incomplete or inaccurate records. Therefore, maintaining complete and accurate medical records does more than protect one’s license. It protects patients’ lives. Implications for Practice The implications of the disciplinary actions that resulted from these documentation errors are that nursing practice, including advanced practice, is still about nursing fundamentals. Documentation is a fundamental principle of clinical professions, including nursing.17 As demonstrated by the details of the infractions for which these NPs appeared before the board, the principles of documentation remain the same, and these are the principles that will assist every NP to: Document what is done. Do it in a timely manner. Do not document the task before doing it or if you did not personally do it. Avoid distractions that lead to documentation errors.
O.A. Oyeleye / The Journal for Nurse Practitioners 15 (2019) 613e617
Do not sign off on another person’s work without verifying. Always document verbal orders. Document clinic visits, and do not falsify records to cover up errors. These principles are as true for advanced practice nurses as they are for students on their first day of nursing school.1
6.
7.
Limitations 8.
One of the limitations of the study is that it covers only 3 years. More years of coverage would indicate a greater scope and trend. In addition, the study reviewed records for only 1 state. Future studies that include more states will provide more robust data.
9.
10.
Clinical Relevance This review has relevance to all NPs engaged in clinical practice and those in academic settings who educate future NPs.
11.
References
12.
1. McCarthy B, Fitzgerald S, O’Shea M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manage. 2018;27(3):491-501. https://doi.org/10.1111/ jonm.12727. Accessed May 6, 2019. 2. American Nurses Association. ANA’s Principles for nursing documentation. Guidance for registered nurses. https://www.nursingworld.org/~4af4f2/ globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf. Accessed May 11, 2019. 3. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing. JONA J Nurs Admin. 2002;32(10):509-523. https://insights.ovid.com/jona-nursing-administration/jnad/2002/10/000/ individual-practice-system-causes-errors-nursing/6/00005110. Accessed May 8, 2019. 4. Brown L. Inadequate record keeping by dental practitioners. Austr Dent J. 2015;60(4):497-502. https://doi.org/10.1111/adj.12258. Accessed May 12, 2019. 5. Hudspeth R. Survey of advanced practice registered nurses disciplinary action. Online J Issues Nurs. 2007;12(2):1-8. https://doi.org/10.3912/OJIN. Vol12No02PPT02. http://ojin.nursingworld.org/MainMenuCategories/
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ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/ No2May07/ArticlePreviousTopic/APRNDisciplinaryActionSurvey.html. Accessed May 12, 2019. Balestra M. The best defense for registered nurses and nurse practitioners: understanding the disciplinary process. J Nurs Law. 2012;15(2):39-44. https:// doi.org/10.1891/1073-7472.15.2.39. Accessed May 14, 2019. Hudspeth R. Understanding discipline of nurse practitioners by boards of nursing. J Nurs Pract. 2009;5(5):365-371. https://doi.org/10.1016/j.nurpra.2009.01.001. Accessed May 20, 2019. Balestra ML. Liability in emergency departments and disciplinary exposure for nurse practitioners. J Nurs Pract. 2016;12(2):80-87. https://doi.org/10.1016/ j.nurpra.2015.09.003. Accessed April 30, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2015, https://www.bon.texas.gov/pdfs/statistics_pdfs// 2015TexasStatistics/Sept2015/apnp-13.pdf. Accessed May 16, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2016, https://www.bon.texas.gov/pdfs/statistics_pdfs// 2016TexasStatistics/Sept2016/apnp-13.pdf. Accessed May 20, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2017, https://www.bon.texas.gov/pdfs/statistics_ pdfs//2017TexasStatistics/Sept2017/apnp-9_17.pdf. Accessed May 20, 2019. Texas Occupations Code. OCC x 301.452(10). Findlaw. https://codes.findlaw. com/tx/occupations-code/occ-sect-301-452.html. Published 2019. Accessed May 12, 2019. Texas Occupations Code. OCC x 301.452(13). Findlaw. https://codes.findlaw. com/tx/occupations-code/occ-sect-301-452.html. Published 2019. Accessed May 12, 2019. 22 TEX. ADMIN. CODE x217.1 1. 22 TEX. ADMIN. CODE x217.1 2. Texas Board of Nursing. Behavior involving lying and falsification. https:// www.bon.texas.gov/pdfs/disciplinary_sanction_policies_pdfs/Lying-andFalsification.pdf. Accessed May 17, 2019. Dabkowski MA. The ABCDEs of nursing. Nursing. 2016;46(2):51-53. https:// doi.org/10.1097/01.nurse.0000476232.80384.1a. Accessed May 14, 2019.
Omobola Awosika Oyeleye, EdD, JD, MSN, MEd, is assistant professor of nursing in the Cizik School of Nursing at the University of TexaseHouston and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Continuing Education
Examining Board Discipline of Nurse Practitioners for Medical Records Infractions Omobola Awosika Oyeleye, EdD, JD a b s t r a c t Keywords: board of nursing discipline documentation medical records nurse practitioner sanctions
This study reviews the records of nurse practitioners (NPs) who were disciplined in Texas by the Board of Nursing between 2015 through 2017, specifically those who were disciplined for documentation-related infractions. The specific details of the infractions are discussed, such as failing to document clinical events that occurred and falsely documenting events that did not occur. Wherever the NPs provided a reason or rationale for their actions, those are also discussed, as are the specific sanctions handed down by the Texas Board of Nursing in each case. Implications for practice and principles that could assist NPs to prevent such infractions are also enumerated. © 2019 Elsevier Inc. All rights reserved.
This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their increased compliance with documentation requirements for their roles, as measured by a score of at least 70% on the CE evaluation quiz. At the conclusion of this activity, the participant will be able to: A. Identify appropriate documentation and its importance B. Evaluate documentation practices that receive board sanctions C. Explain the types of sanctions that can accompany board discipline The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDAapproved recommendations for treatment. This activity has been awarded 1 Contact Hours of which 0 credit are in the area of Pharmacology. The activity is valid for CE credit until November 1, 2021. To receive CE credit, read the article and pass the CE test online at www.npjournal.org/cme/home for a $5 fee.
Introduction Health care documentation is a written or electronic record of the health status of a client. It also contains the care provided to the patient. Documentation of care is the nurse practitioner’s (NP’s) https://doi.org/10.1016/j.nurpra.2019.06.009 1555-4155/© 2019 Elsevier Inc. All rights reserved.
professional responsibility, and it ensures continuity of appropriate care.1 Documentation is expected to be accurate, complete, legible, accessible, and timely. It is a vital medium of communication within a healthcare team. Inaccurate or incomplete documentation can have catastrophic consequences in the nursing environment.2 This analysis of disciplinary actions by the Texas Board of Nursing reveals the documentation-related errors made and the ensuing consequences.3
Background Medical records are a significant part of any health-related practice. They are the depository of information about patients’ medical and health experiences and the basis of health care decisions and research. Because of their significance, they must be complete, accurate, and created in a timely manner. Therefore, the integrity of the information shared among health care professionals for care and research depends on the accuracy of health care records.2,4 This study reviews the errors made by NPs in relation to documentation and reveals the frequency of these errors and their specific types. The reasons given for the errors, where possible, and the sanctions meted out by the Texas Board of Nursing are enlightening. There is a dearth of studies that investigate board actions against advanced practice registered nurses (APRNs) for medical records error. A study by Hudspeth (2007) analyzed the reports of APRN disciplinary actions by 38 boards of nursing in the United States in 2003e2004 and found that most APRNs experienced board sanctions in the areas of chemical impairment, exceeding scope of practice, unprofessional conduct, and safety or abuse of patients. Altogether, there were 688 reported cases in a total of 125,882 APRNs, representing approximately 0.55%.3,5 Another
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O.A. Oyeleye / The Journal for Nurse Practitioners 15 (2019) 613e617
Table Texas Nurse Practitioner Medical Records Disciplinary Data from 2015 to 2017
2015 2016 2017
Approximate No. of NPs
No. of NPs Disciplined Records Reviewed
Total No. NPs Disciplined Medical Records-Related Errors
Total No. Medical Records-Related Infractions
14,825 21,972 24,105
36 49 33
1 10 4
1 11 4
Data from records reviewed from 2015 through 2017. NP ¼ nurse practitioner.
study that investigated 21 case studies of nursing errors from 9 state boards of nursing disciplinary action against registered nurses (not APRNs) found 8 categories of errors, including documentation errors.1 Other articles only inform APRNs about the board disciplinary process4e7 or encourage emergency department NPs to be cognizant of their state’s Nurse Practice Act and the potential for board disciplinary action.8 Purpose This study is aimed at examining the medical record practices of NPs for which they were disciplined by the Texas Board of Nursing, with a view to enlightening NPs about such practices and, ideally, preventing them. Where the NPs provided any type of defense or reason for their actions, those are also discussed. If the public cannot trust the accuracy of patients’ medical records or if health care professionals are unable to confidently base their treatment plans on their patients’ medical records, it could lead to unnecessary tests and hamper the efficiency of the care provided and may jeopardize the patient’s health and life. Methods The Texas Board of Nursing maintains a record of disciplinary actions against Texas nurses on its website. These records are published 4 times a year, in January, April, July, and October and include all the details and board proceedings surrounding each case. The records included in this study are limited to the cases that were decided between January 1, 2015, and December 31, 2017, being the last 3 years for which complete records were available at the time of this writing. Because the publication dates on the website are often many months after the decision dates, the records reviewed in this study were those published between April 2015 and April 2018. Each publication month link was viewed, and the cases with links indicating that they were held by advanced practice nurses were opened, read, and sorted by the specific infractions. In many cases, the nurses committed more than 1 infraction, but only the ones relating to documentation were selected for this study. A second review was done to determine the specific cases where the APRNs were NPs, as opposed to being nurse anesthetists, certified midwives, or clinical nurse specialists. Once the NP cases were identified, they were reviewed and sorted by the NP’s specific errors to determine the themes that existed. In many cases, there was only 1 nurse engaging in 1 type of infraction. In a few cases, 2 or more nurses engaged in the same type of infraction, such as in cases where the NPs prescribed opioids without documentation of appropriate assessment and rationales. In such cases, the nurses’ actions were discussed under their common infraction. Sixteen cases met the specifications. Findings The number of NPs cited in the study for each year represent unduplicated NPs in September of each of the relevant years. Texas
in 2015,9 2016,10 and 2017.11 1n 2015, 68 APRNs received board discipline. Twenty of them were not NPs, and the records for 15 individuals were not available on the website. Therefore, they were not included in the study. In 2016, 68 APRNs were disciplined. Eleven of them were not NPs, and the records for 8 individuals were not available on the website, so they were not included in the study. In 2017, 65 APRNs received board discipline. Six of them were not NPs, and the records for 10 individuals were not available on the website and were not included in the study. The Texas Board of Nursing records from 2015 through 2017 were reviewed specifically for instances in which the NPs were sanctioned by the board for acts that constituted inaccurate or inappropriate medical records documentation. The instances discussed here are not per person but by incident. For example, if 1 NP is sanctioned for more than 1 incident relating to inaccurate/ incomplete medical records, each infraction is counted as a separate one. Therefore, the number of infractions may be higher than the number of NPs sanctioned (see Table). Note that in this article, fictitious initials have been used to describe each NP. The most frequently cited reason for disciplinary action was unprofessional conduct. The 2 most common was conduct that was “likely to deceive, defraud, or injure a patient or the public”12 and “failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the board’s opinion, exposes a patient or other person unnecessarily to risk of harm.”13 The specific cases were about failure to conform to standards of nursing practice relating the Nursing Practice Act, the board’s rules, and local, state, and federal laws; failure to implement measures that promote a safe environment; failure to report and document in an accurate and complete manner; and failure to comply with the authorization granted for practice in an advanced practice role.14 Other violations were about unprofessional conduct relating to unsafe practices that demonstrate the individual carelessly and repeatedly demonstrated that he or she is unable to abide by the minimum acceptable standards of nursing practice, failure to abide by standards of one’s particular areas of practice, and failing to manage patients’ records appropriatelydconduct that is dangerous to a patient, falsifying records, and false, deceptive, or misleading information related to one’s nursing credentials.15 An analysis of all the cases revealed that the cases fell into 2 major categories: Failure to record an event or activity that occurred and affirmatively recording a clinical event or activity that did not occur. Each category includes cases of different NPs sanctioned for different specific infractions. Those cases are discussed next. Failure to Document an Assessment or an Event That Occurred or Should Have Occurred Some of the infractions to be discussed in this section are related to failure to document assessments, failure to document orders, failure to sign patient records, and failure to document clinical rationale.
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Failure to Document Assessments
Failure to Document Own Verbal Order
There were 4 cases in which assessments were lacking, and the NPs prescribed a mix of medications such as hydrocodone, Soma, and/or alprazolam (Xanax), all of the same strength, dose, and quantity, to the same patients. These types of prescriptions, known as “cocktails,” were repeatedly handed out without completely or accurately conducting any appropriate assessment/evaluation or individualized treatment plans. There were no signed informed consent or treatment of chronic pain agreements. There was no documentation of periodic reviews of the patients’ treatment or medical justification for the controlled substances that were prescribed. There was also no documentation of any collaboration with a delegating physician or any measures to monitor the patients for signs of whether they were engaging in drug-seeking or any other abusive behavior. In all 4 cases, there were multiple patients involved, and the NPs did not offer any defense for their actions. In some of the cases, the NPs were sanctioned by limiting their prescriptive privileges for controlled substances, requesting them to surrender all US Drug Enforcement Administration Controlled Substances Registration Certificate and Texas Department of Public Safety Controlled Substances Registration Certificate, where applicable. In 1 of the cases, the NP was sanctioned with a stayed suspension and a 2-year probation. In another case, the NP voluntarily surrendered her license, including controlled substance privileges, and her Texas Department of Public Safety Controlled Substances Registration Number was revoked.
In a case of failure to document a verbal order, O.P., an FNP, had a patient whose international normalized ratio was elevated. During consultation, she instructed the patient to reduce the dosage of Warfarin being taken. However, she made no record of the instruction she had given the patient or the new dosage. The board deemed the inaccurate medical record could potentially injure the patient because other providers would base the patient’s treatment on the incomplete and inaccurate information in the patient’s medical records. In response to the board, O.P. stated that she had relayed the specific instructions to her nurse and that she believed it was the nurse’s responsibility to record it. The board sanctioned her by giving her a warning with stipulations, at which time she asked that her license be placed on inactive status. To reactivate her license in future, she would have to meet all the conditions and stipulations placed on her license.
Failure to Document a Patient’s Clinic Visit A family NP (FNP), T.L., faced disciplinary action because she submitted a bill for the care of a patient. However, the patient had not visited the clinic for any nursing services. In her defense, T.L. claimed that her stepmother was the patient and that she had been a patient for years. However, because the stepmother lived at a distance had only been to the clinic for her first visit. She claimed that subsequent visits, although they took place in her stepmother’s home, had been described as “clinic visits” because she had been using the clinic’s resources. She was sanction with a Warning With Stipulations. The stipulations were not spelled out because T.L. opted to put her license on inactive status. If she ever decided to reactivate her license in future, then the stipulations would be applied at that time.
Failure to Document Rationale for Clinical Decision In another case where there was a lack of documentation of an assessment, S.V., an FNP, worked in a correctional institution. An inmate had initially been granted a “lower-bunk status” by S.V. A lower-bunk status is an order stating that, for clinical reasons, an inmate should only be apportioned a lower bunk and not an upper bunk in the cell. Soon after, S.V. revoked the lower-bunk status without documenting the assessment that led to the revocation. In her defense, S.V. stated that the lower-bunk status had been granted after a review of the inmate’s medical history and a documented physical assessment. However, after the new status had been granted, the inmate’s custody officer informed her that the inmate had been acting and had put on an “Oscar-worthy” performance. This caused S.V. to reevaluate her assessment and to conclude that the result of the assessment was based on deceit. She therefore revoked the inmate’s lower-bunk status and did not document the latter event. She was sanctioned to undergo remedial education.
Failure to Document Discussion With Other Health Care Providers Unlike the previous case in which the NP was disciplined for not recording her instructions to a patient, E.Z., the NP in this case, was sanctioned for, among other things, not documenting her discussion with a registered nurse in the care of a patient. She had received a phone call from the nurses regarding the care of a pediatric patient. E.Z. gave orders to the nurses about actions she wanted them to take and the information to be given to the patient’s mother. However, there was subsequently no documentation in the patient’s medical record that indicated that there had been any telephone discussion with the nurses regarding the patient’s care, nor was there a record of the instructions she gave them. In her defense, the E.Z. stated that she thought the patient was about to be discharged, and she had told the nurses to give some information to the patient so that the patient could share it with her primary care provider. She found out later that the patient had not been discharged. The Board sanctioned her with a warning with stipulations. The stipulations included remedial education. Failure to Sign Patients’ Visit Notes in a Timely Manner Delay in signing was the reason for sanctions against the NP in this case, which indicates that it is not enough to document encounters with patients; it is equally important to complete and sign the documentation in a timely manner. Among many other allegations, V.M. failed to sign numerous patients’ electronic test results and visit notes. There was no indication given regarding how much time had lapsed, but judging by V.M.’s response, it was enough time for the events to have faded from her memory. In her response, V.M. stated that she did not recall the details of those events but that she believed any abnormal results that occurred would have been minute and her facility would always order repeat testing before alerting the primary care providers. The board sanctioned her with a warning with stipulations. The stipulations included remedial education. In another case in which test results were not documented, M.M., an FNP, failed to document, among other things, the results of a rapid strep test and a patient’s past surgical history. M.M.’s response indicated that things moved very fast because the patient fainted during medication administration and while she was charting. Therefore, she did not have time to document those findings. She received a sanction of remedial education and a $500 fine.
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Documenting Activities or Events That Did Not Occur This section describes instances in which assessments were documented although they had not been done or had not been done in the way reported, documenting tests and surgical preparation that had not been done, and signing off on the erroneous action of another caregiver. Documenting Assessments that Were not Done Although some NPs failed to document the assessments that they did, others created inaccurate records by recording assessments that had not been done. A family nurse practitioner, M.J., was sanctioned by the board for documenting patient assessments that had not actually been conducted. The 2 patients involved had not been examined, nor were their vital signs taken. Yet assessment documentation, including vital signs, were recorded. M.J. denied having any fraudulent intent but admitted that she had indeed not assessed 1 of the patients. She stated that this error occurred because she was in a hurry while documenting in the electronic health records. This caused her to input cardiovascular and respiratory data that she had not intended to record. Regarding the second patient, M.J. stated that she had erroneously recorded the information of 1 patient into the record of another patient who had a similar diagnosis. The board sanctioned her with a warning with stipulations. The stipulations included remedial education. In a slightly different twist in which an NP inaccurately documented an event of one kind as another kind that did not occur, family NP S.T. had performed only phone assessments of 3 patients. However, she documented that full physical assessments were conducted, including vital signs. In addition, she indicated in the patients’ medical records that the assessments were conducted in the patients’ homes, even though she had not conducted any home visits. S.T. admitted that only phone assessments were performed because the conditions of the road on those days prevented her from reaching the patients and that the facility allowed phone interviews in lieu of a physical visit if the nurse had an emergency that prevented a physical visit and claimed that she obtained previous assessment evaluation data from the primary care physician. S.T. received a reprimand with a $250 fine. In another case in which an NP documented an assessment that had not been done, G.M., a family NP, documented that she had begun a patient’s history and physical (H&P) at a particular time, although she did not arrive in the building until more than 30 minutes later. She also documented that she began 2 other patients’ H&P at another time, although the patients were not admitted until more than 1 hour after the stated times. G.M. responded that she had erroneously entered the wrong times in the logs. In another allegation against G.M., she had documented that a patient refused an H&P. However, the patient denied that she had seen or spoken to G.M. and that she had refused an H&P. In her response, G.M. stated that she charted this because she had received information from a registered nurse that the patient did not want to see her. She received a warning and a $1,000 fine to be paid within 90 days. Documenting Tests That Had Not Been Done In another case in which a patient’s medical record included an event that did not occur, F.C., a family NP, documented in a patient’s record that an x-ray had been performed. However, it was discovered that the patient had not received an x-ray. Rather, another
patient had received an x-ray, but it was not the patient in whose records F.C. had entered it. Her response did not include an explanation for what led to the error. She was sanctioned to receive remedial education. Signing Off on the Erroneous Action of Another Caregiver In this case relating to an error in documenting in a patient’s electronic medical record, a medical assistant had administered a vaccine to a 5-month-old patient even though the vaccine was not approved for children under 4 years old. C.S., an FNP, signed the progress notes, without recognizing the error made by the medical assistant. This was not discovered until 8 months later by another provider, who wanted to revaccinate the patient. C.S. admitted that she did not notice the medical assistant’s notes or that the vaccine was wrongly administered. However, once it was discovered, she stated that she took steps to remediate and was informed by the manufacturer that the patient did not need to be revaccinated. She received a sanction of a warning with stipulations. The stipulations included remedial education and a limitation on her license that prevented her from working outside the state of Texas in a nurse licensure compact state without obtaining permission from the Texas Board of Nurses and the board of the other state. Conclusion As has been demonstrated in other studies, most nurses are lawabiding and manage to avoid infractions that place them before the board of nursing. The percentage of nurses in Texas who faced board disciplinary action in the years studied was less than 1%. This figure is in alignment with previous data.5 In addition, contrary to many anecdotal reports that threaten nurses and nursing students about “losing their license,” the results in this study seem to indicate that most nurses who come before the board do not commit offenses that warrant getting their licenses revoked. There are consequences that range from a warning up to a license revocation. However, a revocation was not common. Rather, the board considers each situation on a case-by-case basis.16 Although some infractions received serious sanctions and others received light ones, every person who received a sanction of any kind also was required to take remedial classes. The remedial classes generally included a course in Texas nursing jurisprudence and ethics and a course by the National Council of State Boards of Nursing called “Sharpening Critical Thinking Skills.” Other courses may be prescribed, depending on the specific offense. It is important to remember that documentation errors endanger patients in that subsequent providers will rely on either incomplete or inaccurate records. Therefore, maintaining complete and accurate medical records does more than protect one’s license. It protects patients’ lives. Implications for Practice The implications of the disciplinary actions that resulted from these documentation errors are that nursing practice, including advanced practice, is still about nursing fundamentals. Documentation is a fundamental principle of clinical professions, including nursing.17 As demonstrated by the details of the infractions for which these NPs appeared before the board, the principles of documentation remain the same, and these are the principles that will assist every NP to: Document what is done. Do it in a timely manner. Do not document the task before doing it or if you did not personally do it. Avoid distractions that lead to documentation errors.
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Do not sign off on another person’s work without verifying. Always document verbal orders. Document clinic visits, and do not falsify records to cover up errors. These principles are as true for advanced practice nurses as they are for students on their first day of nursing school.1
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Limitations 8.
One of the limitations of the study is that it covers only 3 years. More years of coverage would indicate a greater scope and trend. In addition, the study reviewed records for only 1 state. Future studies that include more states will provide more robust data.
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Clinical Relevance This review has relevance to all NPs engaged in clinical practice and those in academic settings who educate future NPs.
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References
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1. McCarthy B, Fitzgerald S, O’Shea M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manage. 2018;27(3):491-501. https://doi.org/10.1111/ jonm.12727. Accessed May 6, 2019. 2. American Nurses Association. ANA’s Principles for nursing documentation. Guidance for registered nurses. https://www.nursingworld.org/~4af4f2/ globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf. Accessed May 11, 2019. 3. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing. JONA J Nurs Admin. 2002;32(10):509-523. https://insights.ovid.com/jona-nursing-administration/jnad/2002/10/000/ individual-practice-system-causes-errors-nursing/6/00005110. Accessed May 8, 2019. 4. Brown L. Inadequate record keeping by dental practitioners. Austr Dent J. 2015;60(4):497-502. https://doi.org/10.1111/adj.12258. Accessed May 12, 2019. 5. Hudspeth R. Survey of advanced practice registered nurses disciplinary action. Online J Issues Nurs. 2007;12(2):1-8. https://doi.org/10.3912/OJIN. Vol12No02PPT02. http://ojin.nursingworld.org/MainMenuCategories/
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ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/ No2May07/ArticlePreviousTopic/APRNDisciplinaryActionSurvey.html. Accessed May 12, 2019. Balestra M. The best defense for registered nurses and nurse practitioners: understanding the disciplinary process. J Nurs Law. 2012;15(2):39-44. https:// doi.org/10.1891/1073-7472.15.2.39. Accessed May 14, 2019. Hudspeth R. Understanding discipline of nurse practitioners by boards of nursing. J Nurs Pract. 2009;5(5):365-371. https://doi.org/10.1016/j.nurpra.2009.01.001. Accessed May 20, 2019. Balestra ML. Liability in emergency departments and disciplinary exposure for nurse practitioners. J Nurs Pract. 2016;12(2):80-87. https://doi.org/10.1016/ j.nurpra.2015.09.003. Accessed April 30, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2015, https://www.bon.texas.gov/pdfs/statistics_pdfs// 2015TexasStatistics/Sept2015/apnp-13.pdf. Accessed May 16, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2016, https://www.bon.texas.gov/pdfs/statistics_pdfs// 2016TexasStatistics/Sept2016/apnp-13.pdf. Accessed May 20, 2019. Texas Board of Nursing. Currently licensed Texas RNs recognized as advanced practice registered nurses by county and nurse practitioner recognition; September 2017, https://www.bon.texas.gov/pdfs/statistics_ pdfs//2017TexasStatistics/Sept2017/apnp-9_17.pdf. Accessed May 20, 2019. Texas Occupations Code. OCC x 301.452(10). Findlaw. https://codes.findlaw. com/tx/occupations-code/occ-sect-301-452.html. Published 2019. Accessed May 12, 2019. Texas Occupations Code. OCC x 301.452(13). Findlaw. https://codes.findlaw. com/tx/occupations-code/occ-sect-301-452.html. Published 2019. Accessed May 12, 2019. 22 TEX. ADMIN. CODE x217.1 1. 22 TEX. ADMIN. CODE x217.1 2. Texas Board of Nursing. Behavior involving lying and falsification. https:// www.bon.texas.gov/pdfs/disciplinary_sanction_policies_pdfs/Lying-andFalsification.pdf. Accessed May 17, 2019. Dabkowski MA. The ABCDEs of nursing. Nursing. 2016;46(2):51-53. https:// doi.org/10.1097/01.nurse.0000476232.80384.1a. Accessed May 14, 2019.
Omobola Awosika Oyeleye, EdD, JD, MSN, MEd, is assistant professor of nursing in the Cizik School of Nursing at the University of TexaseHouston and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.