What to Chart When You Can’t Chart Everything: Practical Tips for Nursing Documentation

The variation in electronic health records leaves quite a bit of latitude for health care providers to document patient care. Some electronic health records provide many options to capture patient care, while others provide very few options, and both are inherently known for not capturing enough patient care necessary to demonstrate that a standard of care has been met.

An example of documentation that is frequently seen in medical records and is often presented as a problem in the courts has to do with skin breakdown. The prevention of skin breakdown fundamentally requires that patients who are not able to adjust their position are turned every two hours. According to the National Pressure Advisory Panel, many factors are taken into consideration when evaluating a tissue injury, but the first and primary intervention for all patients regardless of “other factors” is to turn patients. When a tissue injury develops (bed sore), stage II, stage III, stage IV, or suspected deep tissue injury, the scrutiny of care will include proving that the patient was, at a minimum, turned to even get close to meeting the standard of care for the prevention of wounds.

Nursing negligence may be alleged for failing to turn the patient every two hours. In addition, if the medical record does not show that the nursing plan of care includes an actual or potential problem addressing alteration in skin integrity it is assumed the turning patients was not done. If a wound develops, it is possible that a correlation can be made between the nurses’ failure to turn the patient led to and contributed to the skin breakdown.

When the medical record clearly demonstrates the patient was turned every two hours and still developed advancing staged wounds, then “other physical factors” are considered as significantly contributory. If the other physical factors do not exist then the documentation may be considered falsified charting. Other physical factors include, but are not limited to: lab results, diabetes, coronary artery disease, previous surgeries, age, infection, etc.

Examples of when care has not been documented and caused additional scrutiny of care are the following:

• Head of bed elevated. Elevation recorded with specific degrees is important when care involves aspiration precautions, limiting sheer, or hemodynamic measurements.

• Response to titration of medications in a critical care area. Titration of medication is expected to occur until a desired effect is attained particularly when orders are written in a protocol format. Medication management recorded in the medical record must reflect appropriate clinical judgment by the nurse.

• Fall prevention interventions. It is not enough to simply record or check off: fall prevention protocol in place. Should a patient fall on your shift, will the records show that what is listed in the protocol was done to prevent the fall? Be specific regarding interventions used when caring for patients determined to be at a higher risk for injury.

Medical record entries must be factual, accurate, complete, and timely. Use the FACT rule. It is very easy to remember.

FACTUAL means there must be enough detail of the facts that the story depicting the patient’s care is clear. Facts are clinical findings a nurse knows to be true. Facts may be lab results, clinical assessment, medications, vital signs, and it could also mean what the patient says. Put what a patient says in “quotations”. First-hand knowledge is another way to determine what should be charted. The best practice is to chart only that which is known to be true. An exception to this practice is during a crisis intervention when the situation utilizes a scribe as one might do during a code or a rapid response. The scribe charts as the events unfold and the documentation is reviewed for accuracy after the patient is stabilized by the health care team.

ACCURATE means the facts must be recorded correctly. The labs must be entered precisely if they are not crossed over through an electronic health record portal system. The movement of a decimal point just one place when recording a medication administered can convey that the dose administered was 10 times or even 100 times more than the dose ordered. Imagine if a record reflected that a nurse administered 10 mg of Atropine instead of 1 mg. How would this error be defended if a catastrophic result seems to be related to the medication error?

COMPLETE medical record entries are thorough entries. Don’t leave the reader guessing about patient care provided. Check the completeness of medical record entries by using: “O P Q R S T”.

“O” is for onset.

“P” is for precipitating or aggravating factors.

“Q” is for quality or quantity

“R” is for radiating

“S” is for situation

“T” is for time (time of day)

The final term, TIMELY. Medical record entries are expected to be written contemporaneously. All that means is charting as soon as possible after the event(s) occur. Timely in a high acuity setting is not the same as timely in a lower level of care, which includes long-term care settings. The higher the level of acuity; more entries are expected to be recorded regarding the patient care. A lower level of acuity will have fewer orders, fewer interventions, fewer interactions which equates to fewer entries representing the care rendered. The frequency of entries should be adjusted according to facility policies and level of patient acuity.

If You Don’t Want to Be Sued, Don’t Be Rude: Maintain Good Rapport With Your Patients

Patients may perceive things very differently than we might think about health care they receive and family members also may perceive things differently than we would expect by what they observe when care is delivered to their loved ones. Therefore, we must assume the attitude of a healthcare provider is quickly filtered through the client’s lens of perception. From a client’s point of view, if things don’t go a planned, they may experience fear, feelings of disappointment, frustration, and even anger. Their anger is frequently directed at the healthcare provider in general. Little things appear large in the client’s eyes and any healthcare provider who happens to be present may be the target of the client’s fear, frustrations and possibly anger.

A nurse’s thoughts may include: “I can’t do anything about how they feel.” To a certain extent, this may be true; however, there are actions nurses can take and should keep in mind to offer reassurance their clients. I have also experienced that some clients can be extremely difficult to care for reasons that may not ever be clearly understood. Their attitude may be less than stellar but, nurses must always remember that the patient is the one who is seeking care for a health issue that may be extremely difficult for them to accept or cope with.

A diagnosis of coronary artery disease many times requires a change in lifestyle or habits. Lifestyle changes will impact individuals in a variety of ways: socially, financially, occupational impact, and self-esteem, any of which their emotions may be manifested in the form of anger and frustration toward anyone who happens to be around them. Many times, nurses become the sounding board for life’s stressors that our clients are experiencing and may be having difficulty coping with. I am certain there are many other real life situations nurses have experienced. We must reflect back to our training in therapeutic communication and revive some of the effective skills that will help client’s to cope with challenges in their life that have been exacerbated by a change in their health status.

Nurses should strive to have patience, communicate professionally, and have empathy. Remember, if the client “feels” you are rude, inconsiderate, impatient, or don’t care, your risk of being sued if significantly greater if things do not go as planned. NOW HEAR THIS: it doesn’t necessarily mean you did anything wrong. It may be all about the client’s perception!

Tips To Increase Rapport With Patients

1. Self-awareness and effective communication skills include the following:

Verbal communication is typically considered the spoken words.
Nonverbal communication includes gestures, expressions, and body language.
Nurses should use positive body language, such as sitting at the same eye level as the client with a relaxed posture that projects interest and attention. Leaning slightly forward will help engage the client. It is generally best to not cross your arms or legs during communication with your clients because this posture erects barriers to your interaction with them. Uncrossed arms and legs projects openness and a willingness to engage in the conversation. Make sure your verbal responses are consistent with your nonverbal messages.

2. Nurses assess and interpret all forms of patient communication.

Silence and Listening are a couple of the most difficult but often the most effective communication techniques to use during verbal interactions.
Passive listening is letting the client do the talking, but,
Active listening reflects on what the client is talking about.

3. Techniques that inhibit therapeutic communication include:

Advice – telling a patient what to do

Agreement – agreeing with a particular viewpoint of a client (the client may not want to change their mind if they thing it opposes what the nurse agrees to)

Challenges – disputing the client’s beliefs with arguments, logical thinking, or direct order (a nurse belittles a client).

Reassurance – telling a client that everything will be OK (this statement may not be true)

Disapproval – judging the client’s situation and behavior (nurse belittles the client).

Remember, a patient’s perception of the care they received is not necessarily what they got! Right or wrong. It starts with a perception which is “real” to the client.

I have been speaking to healthcare organizations and at national conferences for over 15 years. I have published resource books for legal nurse consultants and articles in peer-reviewed journals. I specialize in the legal aspects of healthcare related issues including nursing documentation to assure meaningful use entries meet the regulatory requirements.

Patient Safety: Vigilance, Cyber Awareness, and Take Action

Regulatory requirements, such as The Joint Commission and the Occupational Safety and Health Administration require safety inspections be carried out at regular intervals to assure patient safety. The Nurse Practice Act also requires nurses to safely operate all equipment and use medical devices properly during patient care. When new equipment is introduced to a patient care area, a competency verification should be conducted of the responsible staff who will be using the equipment. This competency verification is typically maintained in the personnel file of the employee for future reference if necessary.

Nurses are taught at some time during their training to always look at the electrical cords of all equipment because a frayed cord is a potential fire hazard. This remains to be true. The temperature of solutions used in heating and cooling pads or blankets may also pose a risk of injury to the patient if the fluid is too hot or too cold. Burns have resulted from improper regulation of temperature associated with a variety of patient care treatment devices. As crazy as it may sound, a simple non-invasive blood pressure cuff has caused patient harm. The device inflated to extreme pressures intermittently over a period of time that ultimately caused permanent nerve damage to the patient’s arm resulting in a clawed hand. A list of equipment frequently involved in patient care issues includes, but is not limited to, the following: volumetric infusion pumps, patient controlled analgesic pumps, blood glucose testing devices, heating pads, cooling/heating blankets, non-invasive blood pressure cuffs, nasal cannula tubing, leg immobilizers, patient lifts, and continuous positive airway pressure machines. An injury exposing the Achilles tendon of an elderly person resulted from a leg immobilizer. The patient’s skin was not checked on a regular basis and as ordered by the physician for breakdown.

Cyber Risk

It seems obvious that inspecting equipment and / or medical devices on periodic regular intervals is a patient safety issue. Inspecting or evaluating the proper functioning of medical equipment should be an added consideration at the time of, or immediately following a rapid response event. We live in a world where amazing cyber technology exists therefore, health care providers must now consider the possibility that technical equipment may have malfunctioned which may have originated from a cyber source. This possibility would never have been considered before. Hacking Healthcare IT in 2016 was published by the Institute for Critical Infrastructure describing how devices that are blue-tooth enabled and have access to the internet, such as automatic implantable cardioverter-defibrillator and pacemakers, patient controlled analgesic pumps, and insulin pumps are at risk for being hacked or reprogrammed.

Take Action:

1. Be hyper-vigilant and open to possibilities of contributing factors never considered before.

2. Conduct a survey of the equipment in the room at the time of the event and inspect it carefully as soon as possible after a Rapid Response or a Code situation. If in doubt, take equipment out of circulation; send it to biomedical engineering for inspection and record your action on an incident report, occurrence report, or a variance report (whatever your institution may call the form). Let the professionals trained in biomedical engineering determine when to return the equipment of concern back to available inventory.

3. Double check the medication rates programmed in the infusion pumps. Sometimes the programming is not correct and guess who is going to held accountable? That’s right You! Double check the pumps by calculating the math yourself.

4. Record the temperature on any equipment or device that displays a temperature. For example: fluid warmers, blanket/pad warmers, heating/cooling blankets, crib warmers, etc. When the temperature is recorded, the medical record conveys that the health care provider was paying attention to details which will support your clinical competence should it be questioned.