- Email: [email protected]
Medical Record Documentation: Legal Aspects in Neonatal Nursing
Medical Record Documentation: Legal Aspects in Neonatal Nursing Rachel C. Cartwright-Vanzant, RN, MS, CNS, LHRM, FNC, LNCC
All nurses have a duty to maintain a complete and accurate recording of all care they provide in accordance with acceptable standards of care. Nurses working in specialty areas of nursing practice such as the neonatal intensive care unit are at greater risk for exposure to litigation simply by the nature of the complexities of the care required of patients. Being aware of common areas of malpractice litigation in neonatal nursing increases the awareness and recognition of potential vulnerable charting practices of nurses. Knowing the “how,” “what,” and “when” of documentation can decrease exposure to litigation by strengthening the accuracy of medical record entries; this is the nurse's best defense. Keywords: Documentation; Malpractice; Medical records; Neonatal; Standards of care
Members of the litigation team scrutinize documentation that reflects the care rendered to the injured party when an untoward event occurs in a clinical setting and when litigation is filed alleging malpractice. Many individuals read the medical record during the development of a lawsuit because the medical record is considered just as important as the testimony in the courtroom. The medical record is the most important piece of evidence in a lawsuit alleging negligent practice of health care providers. Health care providers have a duty to maintain a complete and accurate recording of all relevant events involved in the care rendered to patients assigned to their care. The main tool available to health care providers for communication is the medical record. The medical record may be handwritten, electronic, or a combination of the two, as technology continues to influence the health care delivery systems. Nursing documentation represents only one essential part of the medical record. “If it wasn't charted, it wasn't done” is resonant in litigation. To decrease liability exposure and improve contemporaneous communication, it is beneficial for neonatal nurses to know what to document, how to document, and when to document various aspects of nursing care. According to the CNA HealthPro, “the role of the nurse in medical malpractice litigation has experienced a paradigm shift in the last several years.”1 In the past, plaintiffs' lawyers considered nurses to play a limited role in the care and treatment of patients. Nurses were mere “custodians”—nurses simply followed the physician's orders. Many plaintiffs' lawyers now pursue claims that hold nurses responsible for using From the Medical Legal Concepts, LLC, a consulting firm for the Medical and Legal Professions. Address correspondence to Rachel C. Cartwright-Vanzant, RN, MS, CNS, LHRM, FNC, LNCC, Palm Beach Gardens, FL 33418. E-mail: [email protected]. © 2010 Elsevier Inc. All rights reserved. 1527-3369/1003-0369$36.00/0 doi:10.1053/j.nainr.2010.06.008
professional judgment in the care and treatment they provide. Nurses are now “clinicians”—nurses are highly skilled, educated professionals charged with making correct clinical decisions based on assessment of the patient's clinical picture. The potential risk exposure for nurses as “clinicians” include assessment, communicating a change in the patient condition, initial and subsequent nursing diagnoses, interpretation of diagnostic findings, treatment, change in the treatment plan, and medication administration and dosing. As nurses are named as defendants in medical malpractice lawsuits more frequently, their documentation comes under greater scrutiny. Nursing documentation serves multiple purposes: (1) ensuring quality of care through communication, (2) as legal evidence of the continuity and outcome of care, (3) assisting in establishing standards of practice, and (4) providing a database for trending outcomes as a part of the risk management process.2 During the past 10 years, nursing documentation has gradually shifted from manual to electronic recording and toward standardization of documentation requirements.3 The electronic medical record (EMR) is a legal and business record. The EMR must conform to the same general legal requirements as paper records to ensure that the EMR is legally sound or the EMR risks being challenged as invalid.4 The implementation of the EMR involves extensive changes resulting in increased demands on nursing documentation.5 The accuracy of entries in the medical record is critical. In the legal realm, charting contemporaneously is expected and is the only sure way to ensure accuracy. Contemporaneously means to “chart as you go.” A specific time interval cannot be defined because nurses work in different venues that require documentation intervals that are based on the acuity of the patients served. In general, when the level of acuity is higher, entries are expected to be made more frequently. The acuity in a neonatal intensive care unit (NICU) is high; thus, it would be expected that the documentation of the care would be consistent with more frequent assessments, reassessments, interventions, and monitoring responses to the interventions and outcomes. Nurses working in the NICU are well trained and have
developed their skills in neonatal care as nurse clinicians. Some nurses have advanced their roles to practitioners, clinical specialists, and educators. Nurses have entered into the role of specialized care of the neonates since the 1960s. The National Association of Neonatal Nurses developed the standards for neonatal nursing practice to define the responsibilities and accountability to the profession for all registered nurses who care for high-risk neonates and their families.6 Standards of documentation are defined in federal and state laws. The Code of Regulations7 is used as a resource to validate the continuity and quality of care from the entries made in the medical record. Each state has enacted administrative codes for the practice of nursing called Nurses Practice Acts. The act reveals specific requirements that the nurses shall be responsible and accountable for, including the quality and quantity of care given to patients.8 Most contain language that the nurse has the responsibility to evaluate the response of patients to medical and nursing interventions and involve the appropriate health team members in the evaluation process when warranted. The nursing process must be evident when reviewing the care rendered. Additional federal, state, organizational, and specialty standards apply. The Joint Commission9 publishes hospital accreditation standards annually that include specific standards pertaining to the documentation of care in the medical record. The Joint Commission directs that the medical record contain sufficient information to identify the patient, to support the diagnosis, to justify the treatment, and to document the results accurately. The Centers for Disease Control and Prevention10 is also used as a source for establishing standards of care in an NICU as related to infection control. The Association of Women's Health Obstetric and Neonatal Nurses11 and the National Association of Neonatal Nurses12 are examples of specialty group standards. The Neonatal Resuscitation Program developed by the American Academy of Pediatrics is referenced to evaluate the quality of neonatal resuscitation.13 The most easily obtainable resource for nurses to rely on for standards of care are the procedures, polices, protocols, guidelines, and/or care-maps developed by their organization. These documents will be relied upon heavily in legal proceedings; therefore, it is imperative that nurses be knowledgeable of all the documents applicable to the NICU. Nurses have a duty to be familiar with and follow the standards of the nursing profession and the policies and procedures of the facilities where they work. All nurses are required by law to practice according to their respective state Practice Act. Commonly, organizational policy and procedure may be more restrictive than national standards; and the nurse will be expected to practice within the scope of the organization's policy. Of the nurse specialties, obstetrics/gynecology had the highest average paid indemnity. Birth-related brain damage represented 63.3% of the claims.1 The numbers of cases alleging obstetrical malpractice may be attributed to several issues. The parents may have unrealistic expectations for their labor and delivery experience. There is no precise way of determining the exact moment when an injury or insult occurs that may impair an unborn child for life. When negligence does occur, it may be
NEWBORN
the result of oversight, accident, poor judgment, incompetence, miscommunication, or failure to act.14 There are 15 standards of practice for neonatal nursing.6 The measurement criteria for some are defined specifically in terms of documentation, for example, (1) documents diagnoses in a manner that facilitates the determination of expected outcomes and the plan of care, (2) ensures that the plan is systematically documented and easily retrievable, (3) documents interventions in a retrievable form, (4) documents the coordination of the care, and (5) documents the infant's and family's or caregiver's responses to interventions in a retrievable form. Fundamentally, these few represent the nursing process. The result of operationalizing the nursing process when providing care is critical thinking. The only way to determine if care is rendered according to the current acceptable practices in nursing and medicine is from the story told through the documentation present in the medical record. Common areas of litigation in neonatal nursing13 are neonatal resuscitation, hypoglycemia, hyperbilirubinemia, umbilical venous catheter, and sepsis. Issues related to neonatal resuscitation may include the following: • Failure to provide appropriate neonatal resuscitation, including timely chest compressions. • Failure to use appropriate and necessary resuscitation equipment. • Failure to demonstrate adequate specialty knowledge and competency. Issues related to hypoglycemia may include the following: • Failure to monitor before and after treatments for hypoglycemia. • Failure to reassess infant after interventions. • Failure to administer the correct dose of glucose bolus. Issues related to hyperbilirubinemia may include the following: • Failure to consult with the physician regarding an increased transcutaneous bilirubin or physical assessment. • Failure to recognize risk factors associated with hyperbilirubinemia. • Failure to document physical assessment, laboratory values, and teaching. Issues related to umbilical venous catheter may include the following: • Failure to document placement, vital signs, and assessment. • Failure to prevent dislodgement. • Failure to consult with appropriate provider regarding change in infant status. Issues related to sepsis may include the following: • Failure to document change in infant status. • Failure to consult with appropriate provider regarding change in infant status. The following recommendations that should be applied to your daily practice for strengthening nursing documentation
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are from a legal nurse consultant and risk management perspective.1,2,12 They are not meant to offer legal advice or mandates. Ensure that entries are legible and written in ink. Black ink is preferable; however, blue is also used at times and will certainly identify the original document should copies be made. Date and time all entries. Sign your entries with your first initial and last name followed by your title. In an electronic record, the author is identified through the login in process and will be present on the hard copy when printed. Avoid statements or comments that are subjective about the patient and/or family. The medical record is not to be used as a battleground regarding patients, families, or other health care providers. Refrain from stating your personal opinion in the medical record. Document contemporaneously; as soon after the event as possible. Documentation at the time of the event is the only accurate way to remember the details of the particular event. The more time that passes from the event, the less accurate the entry will be. Details are lost the longer you wait to record your care, and the entries can create discrepancies within the medical record when it is read by others as the care unfolds. Never leave blank spaces on forms. Blank spaces can infer that care has been omitted or not done. Complete all forms according to the guidelines written by your facility regarding the proper completion of all forms used in your department. Use only approved methods for correction of documentation errors. The facility's polices should address the appropriate method for correction in a handwritten medical record. The EMR has specific procedures for correcting errors and should be followed as instructed during the EMR training programs. Never erase, scratch out, or use correction fluid on the record. Alterations in the medical record can give the perception of hiding or covering up something. Use only approved abbreviations. This would include the donot-use abbreviations as specified by The Joint Commission.9 Never add to a previously written entry. If it is necessary to clarify a previously written entry at a later time, it is required to document the entry as a late entry. In a handwritten record, the time your pen is on the paper is the date and time that are written followed by “late entry for” and enter the time you are referring back to. Complete the entry with the necessary additional information. The EMR automatically time stamps the time the key strokes are made when making a late entry. Never backdate an entry. This means entering a date indicating care was done that is not the current date of the entry. A “late entry” is necessary in this case. Always document the assessment before the infant leaves your care and as soon as the infant enters your care. Document the results of each and every nursing assessment. The timing of nursing assessments is critical when determining when the condition of the patient changed. It is imperative that nursing assessments are conducted as soon as possible after care is turned over to you. This will timely record the patient's status when you received them under your care. It is also imperative that nursing assessments be recorded as close to the time that care is being turned over to another provider for the same
136
reason. The documentation of the nursing assessment establishes the health status of your patient and the boundaries of the care you are responsible and accountable for. Record nursing observations, patient complaints or concerns, and instructions given to and conversations held with the patient's family about health care issues. Include the substance of the complaints and any action taken. For example, arranging for the family to discuss further with the physician or providing additional education material as warranted. Furthermore, make note that you allowed time for questions and provided answers or education when appropriate. Document the exact sensory method used when assessing patients. Do not confuse visual, audible, and tactile assessment. The nurse must document significant changes in the patient's condition. Never document an acute abnormality found during assessment without documenting the intervention that follows. A change in the patient's condition warrants a consult with the appropriate physician, and the record should reflect the time the discussion took place. Record all telephone, face-to-face, and electronic contacts and the substance of discussions with other members of the health care team including what is agreed upon and the follow-up. Never document an intervention initiated without documenting the evaluation of the response to the intervention. Document utilization of the chain of command. The chain of command is largely an underused or unused resource. This process should be initiated when the nurse disagrees with physicians' orders based on their nursing judgment. Detailed documentation of the use of the chain of command will decrease the risk of involvement in malpractice litigation when used appropriately and timely. Avoid using the terms doctor aware and doctor notified. The real question is what action the nurse took after the phone call was placed to the provider. The plaintiff and the defense counsel will be interested in knowing this. The documentation should not simply describe “what” happened; it must explain “why” and “when” in addition to the “what.” Use a chronologic format that provides differentiation of each documentation entry Avoid using a documentation format that does not separate each activity or entry by a timed entry. For example, block charting does not provide a clear picture of the sequence of events that is necessary in the NICU; it only provides a summary. Never use medical terminology unless the meaning of the word is known. Use medical terminology when appropriate, and ensure the correct spelling of the terms used. Misspelled words in the written record can decrease your credibility as a nurse. Proper use of medical terminology and anatomical locations when describing care and assessments will actually enhance your credibility in the written medical record.
Conclusion Documentation cannot be separated from patient care. It may be necessary to defer entries of events involved during a crisis, but they cannot be ignored. The longer the delays in documentation
VOLUME 10, NUMBER 3, www.nainr.com
of care, the greater the chance the documentation will be forgotten or inaccurate. Even in the busiest of all days, it is far more advantageous to document timely and completely to avoid making entries in the medical record that are confusing, inaccurate, or absent. To create a medical record that represents good care, neonatal nurses need to create a well-documented record that is timely and demonstrates care that comports with current acceptable nursing practice standards.
References 1. Nurses Services Organization. (2009). CNA HealthPro Nurse Claims Study: an analysis of claims with risk management recommendations 1997-2007. Available at: http://www.nso.com/rnclaimstudy. 2. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. Int J Nurs Pract. 2006;12:366-374. 3. Saranto K, Kinnunen U. Evaluating nursing documentation —research designs and methods: systematic review. J Adv Nurs. 2009;65:464-476. 4. Healthcare Information and Management Systems Society (Himss). The legal electronic medical record; 2006. Available at: www.himss.org.
NEWBORN
5. Tornvalle E, Wahren LK, Wilhelmnsson S. Impact of primary care management on nursing documentation. J Nurs Manag. 2007;15:634-642. 6. The American Nurses Association. Neonatal nursing scope & standards of practice; 2004. Available at: www.nursesbook.org. 7. Code of Federal Regulations, Public Health Title 42. Available at: www.access.gpo.gov/cgi-bin/cfrassemble.cgi? title=200942. 8. The National Council of State Boards of Nursing. Available at: www.ncsbn.org. 9. The Joint Commission. Available at: www.tjc.org. 10. The Center of Disease Control and Prevention. Available at: www.cdc.gov. 11. Association of Women's Health Obstetrics and Neonatal Nursing. Available at: www.AWHONN.org. 12. National Association of Neonatal Nurses. Available at: www.nann.org. 13. Guidash JR. Neonatal nursing. In: Peterson AM, Kopishke L, editors. Legal nurse consulting practices (3rd ed). Boca Raton, FL: American Association of Legal Nurse Consultants. 2010. p. 333-348. 14. Greenwald L, Mondor M. Malpractice and the perinatal nurse. J Perinat Neonatal Nurs. 2003;17:101-109.
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All nurses have a duty to maintain a complete and accurate recording of all care they provide in accordance with acceptable standards of care. Nurses working in specialty areas of nursing practice such as the neonatal intensive care unit are at greater risk for exposure to litigation simply by the nature of the complexities of the care required of patients. Being aware of common areas of malpractice litigation in neonatal nursing increases the awareness and recognition of potential vulnerable charting practices of nurses. Knowing the “how,” “what,” and “when” of documentation can decrease exposure to litigation by strengthening the accuracy of medical record entries; this is the nurse's best defense. Keywords: Documentation; Malpractice; Medical records; Neonatal; Standards of care
Members of the litigation team scrutinize documentation that reflects the care rendered to the injured party when an untoward event occurs in a clinical setting and when litigation is filed alleging malpractice. Many individuals read the medical record during the development of a lawsuit because the medical record is considered just as important as the testimony in the courtroom. The medical record is the most important piece of evidence in a lawsuit alleging negligent practice of health care providers. Health care providers have a duty to maintain a complete and accurate recording of all relevant events involved in the care rendered to patients assigned to their care. The main tool available to health care providers for communication is the medical record. The medical record may be handwritten, electronic, or a combination of the two, as technology continues to influence the health care delivery systems. Nursing documentation represents only one essential part of the medical record. “If it wasn't charted, it wasn't done” is resonant in litigation. To decrease liability exposure and improve contemporaneous communication, it is beneficial for neonatal nurses to know what to document, how to document, and when to document various aspects of nursing care. According to the CNA HealthPro, “the role of the nurse in medical malpractice litigation has experienced a paradigm shift in the last several years.”1 In the past, plaintiffs' lawyers considered nurses to play a limited role in the care and treatment of patients. Nurses were mere “custodians”—nurses simply followed the physician's orders. Many plaintiffs' lawyers now pursue claims that hold nurses responsible for using From the Medical Legal Concepts, LLC, a consulting firm for the Medical and Legal Professions. Address correspondence to Rachel C. Cartwright-Vanzant, RN, MS, CNS, LHRM, FNC, LNCC, Palm Beach Gardens, FL 33418. E-mail: [email protected]. © 2010 Elsevier Inc. All rights reserved. 1527-3369/1003-0369$36.00/0 doi:10.1053/j.nainr.2010.06.008
professional judgment in the care and treatment they provide. Nurses are now “clinicians”—nurses are highly skilled, educated professionals charged with making correct clinical decisions based on assessment of the patient's clinical picture. The potential risk exposure for nurses as “clinicians” include assessment, communicating a change in the patient condition, initial and subsequent nursing diagnoses, interpretation of diagnostic findings, treatment, change in the treatment plan, and medication administration and dosing. As nurses are named as defendants in medical malpractice lawsuits more frequently, their documentation comes under greater scrutiny. Nursing documentation serves multiple purposes: (1) ensuring quality of care through communication, (2) as legal evidence of the continuity and outcome of care, (3) assisting in establishing standards of practice, and (4) providing a database for trending outcomes as a part of the risk management process.2 During the past 10 years, nursing documentation has gradually shifted from manual to electronic recording and toward standardization of documentation requirements.3 The electronic medical record (EMR) is a legal and business record. The EMR must conform to the same general legal requirements as paper records to ensure that the EMR is legally sound or the EMR risks being challenged as invalid.4 The implementation of the EMR involves extensive changes resulting in increased demands on nursing documentation.5 The accuracy of entries in the medical record is critical. In the legal realm, charting contemporaneously is expected and is the only sure way to ensure accuracy. Contemporaneously means to “chart as you go.” A specific time interval cannot be defined because nurses work in different venues that require documentation intervals that are based on the acuity of the patients served. In general, when the level of acuity is higher, entries are expected to be made more frequently. The acuity in a neonatal intensive care unit (NICU) is high; thus, it would be expected that the documentation of the care would be consistent with more frequent assessments, reassessments, interventions, and monitoring responses to the interventions and outcomes. Nurses working in the NICU are well trained and have
developed their skills in neonatal care as nurse clinicians. Some nurses have advanced their roles to practitioners, clinical specialists, and educators. Nurses have entered into the role of specialized care of the neonates since the 1960s. The National Association of Neonatal Nurses developed the standards for neonatal nursing practice to define the responsibilities and accountability to the profession for all registered nurses who care for high-risk neonates and their families.6 Standards of documentation are defined in federal and state laws. The Code of Regulations7 is used as a resource to validate the continuity and quality of care from the entries made in the medical record. Each state has enacted administrative codes for the practice of nursing called Nurses Practice Acts. The act reveals specific requirements that the nurses shall be responsible and accountable for, including the quality and quantity of care given to patients.8 Most contain language that the nurse has the responsibility to evaluate the response of patients to medical and nursing interventions and involve the appropriate health team members in the evaluation process when warranted. The nursing process must be evident when reviewing the care rendered. Additional federal, state, organizational, and specialty standards apply. The Joint Commission9 publishes hospital accreditation standards annually that include specific standards pertaining to the documentation of care in the medical record. The Joint Commission directs that the medical record contain sufficient information to identify the patient, to support the diagnosis, to justify the treatment, and to document the results accurately. The Centers for Disease Control and Prevention10 is also used as a source for establishing standards of care in an NICU as related to infection control. The Association of Women's Health Obstetric and Neonatal Nurses11 and the National Association of Neonatal Nurses12 are examples of specialty group standards. The Neonatal Resuscitation Program developed by the American Academy of Pediatrics is referenced to evaluate the quality of neonatal resuscitation.13 The most easily obtainable resource for nurses to rely on for standards of care are the procedures, polices, protocols, guidelines, and/or care-maps developed by their organization. These documents will be relied upon heavily in legal proceedings; therefore, it is imperative that nurses be knowledgeable of all the documents applicable to the NICU. Nurses have a duty to be familiar with and follow the standards of the nursing profession and the policies and procedures of the facilities where they work. All nurses are required by law to practice according to their respective state Practice Act. Commonly, organizational policy and procedure may be more restrictive than national standards; and the nurse will be expected to practice within the scope of the organization's policy. Of the nurse specialties, obstetrics/gynecology had the highest average paid indemnity. Birth-related brain damage represented 63.3% of the claims.1 The numbers of cases alleging obstetrical malpractice may be attributed to several issues. The parents may have unrealistic expectations for their labor and delivery experience. There is no precise way of determining the exact moment when an injury or insult occurs that may impair an unborn child for life. When negligence does occur, it may be
NEWBORN
the result of oversight, accident, poor judgment, incompetence, miscommunication, or failure to act.14 There are 15 standards of practice for neonatal nursing.6 The measurement criteria for some are defined specifically in terms of documentation, for example, (1) documents diagnoses in a manner that facilitates the determination of expected outcomes and the plan of care, (2) ensures that the plan is systematically documented and easily retrievable, (3) documents interventions in a retrievable form, (4) documents the coordination of the care, and (5) documents the infant's and family's or caregiver's responses to interventions in a retrievable form. Fundamentally, these few represent the nursing process. The result of operationalizing the nursing process when providing care is critical thinking. The only way to determine if care is rendered according to the current acceptable practices in nursing and medicine is from the story told through the documentation present in the medical record. Common areas of litigation in neonatal nursing13 are neonatal resuscitation, hypoglycemia, hyperbilirubinemia, umbilical venous catheter, and sepsis. Issues related to neonatal resuscitation may include the following: • Failure to provide appropriate neonatal resuscitation, including timely chest compressions. • Failure to use appropriate and necessary resuscitation equipment. • Failure to demonstrate adequate specialty knowledge and competency. Issues related to hypoglycemia may include the following: • Failure to monitor before and after treatments for hypoglycemia. • Failure to reassess infant after interventions. • Failure to administer the correct dose of glucose bolus. Issues related to hyperbilirubinemia may include the following: • Failure to consult with the physician regarding an increased transcutaneous bilirubin or physical assessment. • Failure to recognize risk factors associated with hyperbilirubinemia. • Failure to document physical assessment, laboratory values, and teaching. Issues related to umbilical venous catheter may include the following: • Failure to document placement, vital signs, and assessment. • Failure to prevent dislodgement. • Failure to consult with appropriate provider regarding change in infant status. Issues related to sepsis may include the following: • Failure to document change in infant status. • Failure to consult with appropriate provider regarding change in infant status. The following recommendations that should be applied to your daily practice for strengthening nursing documentation
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are from a legal nurse consultant and risk management perspective.1,2,12 They are not meant to offer legal advice or mandates. Ensure that entries are legible and written in ink. Black ink is preferable; however, blue is also used at times and will certainly identify the original document should copies be made. Date and time all entries. Sign your entries with your first initial and last name followed by your title. In an electronic record, the author is identified through the login in process and will be present on the hard copy when printed. Avoid statements or comments that are subjective about the patient and/or family. The medical record is not to be used as a battleground regarding patients, families, or other health care providers. Refrain from stating your personal opinion in the medical record. Document contemporaneously; as soon after the event as possible. Documentation at the time of the event is the only accurate way to remember the details of the particular event. The more time that passes from the event, the less accurate the entry will be. Details are lost the longer you wait to record your care, and the entries can create discrepancies within the medical record when it is read by others as the care unfolds. Never leave blank spaces on forms. Blank spaces can infer that care has been omitted or not done. Complete all forms according to the guidelines written by your facility regarding the proper completion of all forms used in your department. Use only approved methods for correction of documentation errors. The facility's polices should address the appropriate method for correction in a handwritten medical record. The EMR has specific procedures for correcting errors and should be followed as instructed during the EMR training programs. Never erase, scratch out, or use correction fluid on the record. Alterations in the medical record can give the perception of hiding or covering up something. Use only approved abbreviations. This would include the donot-use abbreviations as specified by The Joint Commission.9 Never add to a previously written entry. If it is necessary to clarify a previously written entry at a later time, it is required to document the entry as a late entry. In a handwritten record, the time your pen is on the paper is the date and time that are written followed by “late entry for” and enter the time you are referring back to. Complete the entry with the necessary additional information. The EMR automatically time stamps the time the key strokes are made when making a late entry. Never backdate an entry. This means entering a date indicating care was done that is not the current date of the entry. A “late entry” is necessary in this case. Always document the assessment before the infant leaves your care and as soon as the infant enters your care. Document the results of each and every nursing assessment. The timing of nursing assessments is critical when determining when the condition of the patient changed. It is imperative that nursing assessments are conducted as soon as possible after care is turned over to you. This will timely record the patient's status when you received them under your care. It is also imperative that nursing assessments be recorded as close to the time that care is being turned over to another provider for the same
136
reason. The documentation of the nursing assessment establishes the health status of your patient and the boundaries of the care you are responsible and accountable for. Record nursing observations, patient complaints or concerns, and instructions given to and conversations held with the patient's family about health care issues. Include the substance of the complaints and any action taken. For example, arranging for the family to discuss further with the physician or providing additional education material as warranted. Furthermore, make note that you allowed time for questions and provided answers or education when appropriate. Document the exact sensory method used when assessing patients. Do not confuse visual, audible, and tactile assessment. The nurse must document significant changes in the patient's condition. Never document an acute abnormality found during assessment without documenting the intervention that follows. A change in the patient's condition warrants a consult with the appropriate physician, and the record should reflect the time the discussion took place. Record all telephone, face-to-face, and electronic contacts and the substance of discussions with other members of the health care team including what is agreed upon and the follow-up. Never document an intervention initiated without documenting the evaluation of the response to the intervention. Document utilization of the chain of command. The chain of command is largely an underused or unused resource. This process should be initiated when the nurse disagrees with physicians' orders based on their nursing judgment. Detailed documentation of the use of the chain of command will decrease the risk of involvement in malpractice litigation when used appropriately and timely. Avoid using the terms doctor aware and doctor notified. The real question is what action the nurse took after the phone call was placed to the provider. The plaintiff and the defense counsel will be interested in knowing this. The documentation should not simply describe “what” happened; it must explain “why” and “when” in addition to the “what.” Use a chronologic format that provides differentiation of each documentation entry Avoid using a documentation format that does not separate each activity or entry by a timed entry. For example, block charting does not provide a clear picture of the sequence of events that is necessary in the NICU; it only provides a summary. Never use medical terminology unless the meaning of the word is known. Use medical terminology when appropriate, and ensure the correct spelling of the terms used. Misspelled words in the written record can decrease your credibility as a nurse. Proper use of medical terminology and anatomical locations when describing care and assessments will actually enhance your credibility in the written medical record.
Conclusion Documentation cannot be separated from patient care. It may be necessary to defer entries of events involved during a crisis, but they cannot be ignored. The longer the delays in documentation
VOLUME 10, NUMBER 3, www.nainr.com
of care, the greater the chance the documentation will be forgotten or inaccurate. Even in the busiest of all days, it is far more advantageous to document timely and completely to avoid making entries in the medical record that are confusing, inaccurate, or absent. To create a medical record that represents good care, neonatal nurses need to create a well-documented record that is timely and demonstrates care that comports with current acceptable nursing practice standards.
References 1. Nurses Services Organization. (2009). CNA HealthPro Nurse Claims Study: an analysis of claims with risk management recommendations 1997-2007. Available at: http://www.nso.com/rnclaimstudy. 2. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. Int J Nurs Pract. 2006;12:366-374. 3. Saranto K, Kinnunen U. Evaluating nursing documentation —research designs and methods: systematic review. J Adv Nurs. 2009;65:464-476. 4. Healthcare Information and Management Systems Society (Himss). The legal electronic medical record; 2006. Available at: www.himss.org.
NEWBORN
5. Tornvalle E, Wahren LK, Wilhelmnsson S. Impact of primary care management on nursing documentation. J Nurs Manag. 2007;15:634-642. 6. The American Nurses Association. Neonatal nursing scope & standards of practice; 2004. Available at: www.nursesbook.org. 7. Code of Federal Regulations, Public Health Title 42. Available at: www.access.gpo.gov/cgi-bin/cfrassemble.cgi? title=200942. 8. The National Council of State Boards of Nursing. Available at: www.ncsbn.org. 9. The Joint Commission. Available at: www.tjc.org. 10. The Center of Disease Control and Prevention. Available at: www.cdc.gov. 11. Association of Women's Health Obstetrics and Neonatal Nursing. Available at: www.AWHONN.org. 12. National Association of Neonatal Nurses. Available at: www.nann.org. 13. Guidash JR. Neonatal nursing. In: Peterson AM, Kopishke L, editors. Legal nurse consulting practices (3rd ed). Boca Raton, FL: American Association of Legal Nurse Consultants. 2010. p. 333-348. 14. Greenwald L, Mondor M. Malpractice and the perinatal nurse. J Perinat Neonatal Nurs. 2003;17:101-109.
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