In 2003 the American Nurses Association (ANA) introduced its Principles for Documentation,1 based on the ANA's Code of Ethics for Nurses with Interpretive Statements and Nursing: Scope and Standards of Practice.2, 3 These principles suggest that documentation systems must
* be designed in consultation with nursing staff so that the concerns of nurses are addressed before the documentation system is implemented.
* promote a "record once, read many times" approach to avoid duplicate recording by different providers.
* use ANA-recognized data sets (for example, the ANA's National Database of Nursing Quality Indicators, developed in collaboration with the University of Kansas School of Nursing, which compiles data on nursing-sensitive indicators, including patient falls and pressure ulcers, staff mix, nursing hours per patient day, job satisfaction, and nurse education and certification4).
* be readily accessible by nurses and support data analysis.
* encourage nurses to critically evaluate the system of documentation and patient outcomes.
It's important to understand that these standards of documentation aren't tied to any specific charting system. Rather, they are general principles that can be applied to any system an organization adopts. Some clinical settings, for example, use a paper form-based, narrative style of charting; others use setting- or unit-specific flow sheets; still others use charting by exception, recording only exceptions to normal findings. Regardless of the system used, the purpose of documentation, from a legal perspective, is always to accurately and completely record the care given to patients, as well as their response to that care. (For more, see Charting the Course, page 59, and The Purpose of Medical Record Documentation, page 60.)
HARTZELL V. CITY OF WARREN, ET AL.
In civil litigation in which there is alleged negligence or nursing malpractice, documentation in the medical record can exonerate accused nurses regardless of their practice setting. Such was the case in Hartzell v. City of Warren, et al., in which a nurse who worked at a correctional facility was named as a defendant.5 The case was decided by the Michigan Court of Appeals in May 2005.
In this case, Debra Cisco, RN, was one of a number of defendants who was accused of providing grossly negligent, life-ending nursing care to Robbie Hartzell. Cisco's documentation of her interaction with Hartzell, as well as her deposition testimony, led the appellate court to conclude that she was not grossly negligent and did not commit malpractice.
Cisco evaluated Hartzell at 9:30 PM on July 27, 1998, at the Macomb County Jail in Mt. Clemens, Michigan. She measured his blood pressure and determined that it was within "normal and acceptable limits" at 132/94 mmHg. She noted that Hartzell said that, after surgical repair of a cerebral aneurysm and intracerebral hemorrhage a month before, he'd begun taking 0.2 mg Catapres (clonidine) by mouth twice daily to manage hypertension. He said that he had no other medical problems that required immediate attention. Because Hartzell had not yet been examined by a physician, Cisco arranged for that to occur the following day.
The next day, July 28, at 12:55 PM, Ernest Bedia, MD, examined Hartzell and determined that his blood pressure was 180/108 mmHg. The physician ordered blood pressure monitoring twice weekly; 0.2 mg Catapres and Ecotrin (aspirin) once daily.
The medical record indicated that, according to the physician's orders, Catapres was given at 3:15 PM on July 28. The initials of another nurse, Janie Kushniruk, were on the patient's chart, indicating that she had administered the medication, but Kushniruk testified that she had not given the medication and had not given anyone permission to sign her initials on the chart. Hartzell was found unconscious with a blood pressure of 280/200 mmHg. He died two days later at a nearby hospital. In the lawsuit, representatives of Hartzell's estate alleged, among other things, that Hartzell had been denied proper medical care, including medication, an omission that caused his death.
After reviewing the evidence, the appellate court concluded that neither Bedia nor Cisco was deliberately indifferent to Hartzell's serious medical needs. To support this conclusion, the court pointed to the documentation submitted by Cisco, concluding that there was no indication that Cisco, the physician, or anyone else intentionally denied or unreasonably delayed treatment. Accordingly, the Michigan Court of Appeals precluded Hartzell's estate from pursuing its claims against Cisco and Bedia.
This case demonstrates that any interaction with a patient can result in litigation. Therefore, on even the busiest days, nurses need to complete documentation carefully and in accordance with the standards of care (for more, see "Documentation, Part II: The Best Evidence of Care," page 61). As long as the care provided is consistent with the standards of care, nurses who follow documentation procedures as described here will be in a good position to defend themselves if they're ever accused of failing to6
* assess, analyze, and act according to the level of care the patient needs.
* ascertain the patient's wishes concerning self-determination.
* make an appropriate nursing diagnosis, identify the patient's needs, and implement an appropriate plan of care.
* communicate promptly any clinically significant changes or trends in the patient's condition or responses to interventions.
* take appropriate action.
* protect patient privacy.
* act as a patient advocate.
PRESERVING THE MEDICAL RECORD
Regardless of the practice setting, nurses must preserve the integrity of the medical record in the following ways.
* Accurate and complete patient information must be entered on all paper and electronic documents.
* Other diagnostic records and reports, including but not limited to electrocardiogram, fetal monitor, and other diagnostic recording strips; consultation, laboratory, radiology, and other test reports; procedure results; and other forms must be properly labeled, sequentially listed or referenced, and kept with the medical record.
* All unofficial papers, such as a nurse's to-do list, must be removed from the patient care area so they are not included in the medical record.
* All documentation practices must be consistent with the standards associated with the patient population for which care is being provided. This applies to both the schedule according to which documentation is to be performed and the stylistic conventions and substance of the notations themselves. Any special documentation requirements for specialty and high-risk settings must also be followed.
* Abbreviations on the Joint Commission's Official "Do Not Use" List should not be used (go to http://www.jointcommission.org/patientsafety/donotuselist). Avoid ambiguous abbreviations such as "SOB," which can mean either "shortness of breath" or "side of bed."
* Nurses must read medical record entries and assess the patient themselves before cosigning another clinician's assessment records.
* "Late entries" must be made in accordance with acceptable organizational standards.
* Interventions delineated in critical pathways, guidelines, policies, procedures, protocols, standards, and care plans must be followed and documented. If a standard recommendation is not followed, the reasons for this must be documented.
* The patient's response to interventions and the clinician's response to a worsening condition or worrisome indicator must be recorded promptly.
* Physicians' orders must be transcribed and accomplished as quickly as possible.
* Discharge instructions and the patient's response to them must be noted.
* Personal, critical, and judgmental opinions concerning health care providers, patients, and family members must not be recorded.
* All attempts to contact other health care professionals must be documented, including the time of the attempt or contact. Do not document any speculation about why another provider might not have responded promptly.
Nurses who use paper medical records must also
* write concisely and legibly, using correct spelling and grammar.
* use a black ballpoint pen.
* draw a single line through erroneous entries to identify them as erroneous.
* use addendum pages as needed in a manner consistent with organizational standards.
From a legal perspective, documentation-related challenges arise when there is inattention to or inconsistency in recording
* the date, time, and patient's name on each page of the medical record.
* only sequential, factual information, even when deviations occur (such as when a medication or other treatment is given later than ordered).
* the time at which the assistance of other providers is requested.
* admission data and the patient's wishes with regard to self-determination, using the patient's verbatim responses when possible.
* pain intensity, location, accompanying factors, the interventions performed, and the patient's responses.
* steps taken to follow preadministration protocols or policies related to blood, blood products, chemotherapeutic agents, and other high-risk infusions or medications.
* assessment data, the interventions performed, and the patient's responses, noting deviations from normal or expected findings and actions taken in light of those findings.
* interactions between the patient and other clinicians.
* steps taken to preserve the patient's privacy and to address any related concerns of the patient or family, including steps taken through the organization's chain of command.
* transfer times, modes of transfer, and patient status during and following transfer.
* completed treatments, procedures, and interventions, as well as those that have not been completed and the reason they were not completed.
* the patient's response to medication administration.
Charting the Course
A free online video presentation on different charting methods.
Do you have questions about the policies and procedures that govern charting in your workplace? Do you know what-and what not-to chart? Do you know why it's important to document all of the care you provide to patients factually, accurately, completely, and promptly?
If you're in doubt about the answers to any of these questions, you might benefit by viewing a free, 30-minute online video presentation, Charting the Course for Nursing: Who Benefits When Charting Is Complete? (go to http://www.nursingcenter.com/AJNdocumentation). The video program, supported in part by a grant from the Nurses Service Organization, explains several methods of charting and can help you evaluate the method used at your workplace.
James M. Stubenrauch
senior editor
The Purpose of Medical Record Documentation
Hartzell v. City of Warren, et al. illustrates how the medical record can be a powerful and persuasive multipurpose document. The medical record is used for
* substantiating the health condition, illness, or presenting concern of a patient.
* communicating among health care professionals.
* recording the patient's response to care.
* auditing care for quality improvement, third-party payment, and governmental and regulatory purposes.
* conducting research.
* resolving competency, disability, guardianship, and other legal issues.
* teaching health care professionals about caring for patients.
REFERENCES