Tag Archives: charting

MY DOG ATE MY HOMEWORK

Nursing Talk

Dear Cassandra,

Why is American Home Health so hung up on little things like clinical notes? Almost every week someone from the office contacts me about my clinical notes. I go to work and take care of my client. Sometimes I don’t have time to write the nursing notes. Sometimes the supervisor says she can’t read them. Once I spilled coffee on the clinical notes. Once the client’s dog ate them. What am I supposed to do?

Perplexed in Palos Hills

Dear Perplexed:

What are you supposed to do? What kind of question is that? You know that you are supposed to write clear, legible nursing notes every two hours. You know the times and dates on the nursing notes have to match the times and dates you Clock In/Clock Out. You know that the nurse working the last shift of the week is to mail the nursing notes to the office. You know one week’s worth of notes is to remain in the home for reference.

Frankly, I’m surprised you haven’t been fired by now. Your excuses sound like the excuses of a high school student. The dog ate the nursing notes. Please! Every teacher has heard that excuse. So you spilled coffee on the notes. Well, rewrite them. So you have poor handwriting. Well, print.

Maybe you think good handwriting is not important. A man recently tried to rob a bank. His handwriting was so poor that the teller could not read the note. She asked him to write the note over again. Instead, he fled. The teller, of course, had activated the silent alarm. The robber was arrested by police waiting outside the bank.

Why is it critical to send the notes to the office in a timely manner? In some cases, American Home Health cannot bill for services without a copy of the clinical notes to accompany the invoice. In addition, in the event of an audit by the Department of Specialized Care for Children (DSCC) or the Illinois Department of Public Health (IDPH), the auditors review the clinical notes to determine the quality of care. The auditors also compare the times recorded on the notes to time billed. Discrepancies can mean paybacks to the funding body. If nursing care is not documented, it is as if it did not happen. That brings questions of possible fraud. Do you want to be accused of fraud? If, God forbid, a child should die under unusual circumstances, the nursing notes would be reviewed by the authorities.

Always proofread your clinical notes. If you work for multiple clients, check to be sure you wrote the correct client’s name on the clinical notes. Did you sign and date the notes? Did you sign the notes using the name which appears on your license even if you have a different legal name?

Do your clinical notes contain medical bloopers? Below are actual statements found in clinical notes of other medical providers:

“Patient was unresponsive and in no distress.”

“Patient is non-verbal, non-communicative, and offers no complaints.”

“Patient was apprehended and guarded.”

Do your notes contain a malapropism? That is an unintentionally humorous misuse or distortion of a word or phrase especially the use of a word sounding somewhat like the one intended. Did you write, “We had to use the fire distinguisher.” Did you say, “The client had an expensive pendulum around his neck, and it got caught in the Hoyer lift.”

What else can you do to correct the situation? Get a Palmer method handwriting manual and start practicing to improve your handwriting. Talk with your supervisor about time management skills. Keep liquids away from the clinical notes. Keep the notes in a safe place so dogs and children can’t get them. If you are responsible for sending in the notes, be sure you send the whole weeks worth of notes and that no pages are missing. Don’t wait until the end of your shift to document the events of the entire shift. Above all, change your attitude about the importance of clinical notes. Your job depends on it.

—Cassandra

Note: First published on American Home Health's news, January 2012.

Documentation Made Easy

Charting

The Basics

Right Chart: Check that you have the correct chart before writing.

Penmanship: All your documentation is to be legible so anyone can read it. If you have poor penmanship, begin to print. Your printing will make it easier to read your notes. Now that your nursing notes are legible, let’s talk about the basics. Use permanent black ink pen. Other colors do not copy well.

Date and Time: Date and time every entry. The date should include the year; the time should indicate am or pm or be in military time. Don’t chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.

Client’s history (including unhealthy conditions or risky heath habits such as scalp lice, smoking, failure to take prescribed medication, specific non-compliance issues and events, etc.) A client’s history is usually reflective of trends and may offer valuable hints about what to expect in the future.

Subjective Information: It is important that you chart any subjective information. Document what you hear, what the client says, what the caregivers say, comments to you about how they feel, feelings of anxiety or depression, etc. Use direct quotes and place quotation marks around the quote. Chart a client’s refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client’s physician and document your calls.

Objective Information: Chart your observations, what do you see, vital signs, hard data such as any and all assessment information. It is especially important to document changes in health status such as the emergence of a productive cough, difficulty in breathing or changes in vital signs from their baseline. Did you address: mental status, functional status, mobility, cognitive ability, speech? Oftentimes when you are in the home every day you forget that the people reading your notes do not know the client so you need to show them on paper.

Interventions: Document any actions that you did in response to any of your observations and the client’s response to your actions. These responses to your interventions are commonly called client outcomes. Chart the time you gave a medication, the route you gave it and the client’s response. If a medication is a PRN, chart the reason it was given and the client’s response to the medication (did it give the desired effect). Chart precautions, preventive measures used as well as any safety measures enacted, such as bed rails.

Client outcomes: Chart the client’s response to your interventions, including those that are deviations from what you expected. For example: if a client is in pain, observe and document how that pain is experienced both objectively (what you see) and subjectively (what you hear). Record where the pain is and the level of intensity or severity (use a pain scale to do that). Record the medication and the backrub you give to relieve the pain and whether or not those actions were effective, i.e., did the pain persist, recur, or go away?

Document the client, family member or significant other’s actual response (verbal or non-verbal) to any aspect of care provided even if you were not the one providing it. Doing so indicates that you have evaluated the results of care. It is perfectly acceptable to chart the client’s verbal responses in the record as long as you use quotation (“) marks. Non-verbal responses should be described in as much detail as possible.

Make sure your documentation reflects the nursing process and your professional capabilities. Chart completely, concisely and accurately (“Tell it like it is.”). Write clear sentences that get right to the point. Use simple, precise words. Don’t be afraid to use the word “I.”

Be sure to record your full name, credentials and job title in the required section on documentation forms. Some forms will ask you to record your initials as well. Your signature must be in cursive writing so a word of final caution: do take the time to sign your name legibly.

Beyond The Basics

Client Education and Instruction: Other information that needs to be recorded in the medical record includes any education or instructions you give to the client, his family or significant other. Anytime there is a new medication or treatment the client, family member and other personnel must be educated and informed. Documentation of these actions is required. Include the fact that you informed the client/caregiver of the new order; chart the education of dosage, actions, side effects and schedule; chart that you made changes on the medication administration record or task sheets (if applicable); chart how you were able to communicate the new orders to other nursing personnel responsible for the client’s care, document your communications regarding the new orders to the office.

Check Off Sheets: In some instances a preprinted, standardized check off form may be used where all you have to do is check off or initial what you have done. The only time you may have to write any notes is when something is specific or unique to this particular client, something that can’t be included on a standardized check off form. Remember: if you do not check off items, it means that legally the care was not done.

Phone Calls: We don’t often think about phone calls, but they can contain certain information for which we have obligations such as advice that we may give to a client or a phone order that we may take from a doctor. To protect yourself in these kinds of phone conversations, a detailed summary of your conversations is charted in the client record.

Details of each call should include:

  1.  Date and time of the call
  2. Caller’s name, position or credentials, call back phone number and address
  3. Reason for the call, request, complaint
  4. Your response to the call, advice you gave, protocol you followed (if applicable)
  5. Others that you notified as a result of the call
  6. Your name and credentials
  7. If taking doctor’s orders, transcription of the orders word for word and documentation that you read the orders back for verification.

More Do’s to Make Charting Successful

  • Chart as soon as possible after giving care; don’t wait to chart until the end of your work day. Chart often enough to tell the whole story.
  • If you remember an important point after you’ve completed your documentation, chart the information with a notation that it’s a “late entry.” Include the date and time of the late entry.
  • Chart all of the details relating to visits by physicians or other members of the health care team such as the teacher, therapist, case worker, dietician, social worker, etc. Describe the purpose of the visit, the name of the visitor, the time spent with the client and the outcome of the visit.
  • If you don’t give a medication, circle the time and document the reason for the omission.
  • If information on a form such as a flow sheet doesn’t apply to your client, write NA (not applicable) in the space provided.
  • Use only commonly used or approved abbreviations and symbols. Refer to the procedure manual for a list of approved abbreviations. When in doubt spell out the words. Remember many medications have similar names but very different actions.
  • When documentation continues from one page to the next, sign the bottom of the first page. At the top of the next page, write the date, time and “continued from previous page.” Make sure each page contains the client’s identifying information, date and year.
  • Re-read your documentation. You need to paint a picture of the client. Pretend you know nothing about the client. Then read your notes and see if your notes are capable of making you see the client as he/she really is.

-By Janet Fulfs, President

Note: First published on American Home Health's news, October 2011.

Documentation, Standards & Liability Part III

Nurse Charting

The Basics

Right Chart: Check that you have the correct chart before writing.

Penmanship: All your documentation is to be legible so anyone can read it. If you have poor penmanship, begin to print. Your printing will make it easier to read your notes. Now that your nursing notes are legible, let’s talk about the basics. Use permanent black ink pen. Other colors do not copy well.

Date and Time: Date and time every entry. The date should include the year; the time should indicate am or pm or be in military time. Don’t chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.

Client’s history (including unhealthy conditions or risky heath habits such as scalp lice, smoking, failure to take prescribed medication, specific non-compliance issues and events, etc.) A client’s history is usually reflective of trends and may offer valuable hints about what to expect in the future.

Subjective Information: It is important that you chart any subjective information. Document what you hear, what the client says, what the caregivers say, comments to you about how they feel, feelings of anxiety or depression, etc. Use direct quotes and place quotation marks around the quote. Chart a client’s refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client’s physician and document your calls.

Objective Information: Chart your observations, what do you see, vital signs, hard data such as any and all assessment information. It is especially important to document changes in health status such as the emergence of a productive cough, difficulty in breathing or changes in vital signs from their baseline. Did you address: mental status, functional status, mobility, cognitive ability, speech? Oftentimes when you are in the home every day you forget that the people reading your notes do not know the client so you need to show them on paper.

Interventions: Document any actions that you did in response to any of your observations and the client’s response to your actions. These responses to your interventions are commonly called client outcomes. Chart the time you gave a medication, the route you gave it and the client’s response. If a medication is a PRN, chart the reason it was given and the client’s response to the medication (did it give the desired effect). Chart precautions, preventive measures used as well as any safety measures enacted, such as bed rails.

Client outcomes: Chart the client’s response to your interventions, including those that are deviations from what you expected. For example: if a client is in pain, observe and document how that pain is experienced both objectively (what you see) and subjectively (what you hear). Record where the pain is and the level of intensity or severity (use a pain scale to do that). Record the medication and the backrub you give to relieve the pain and whether or not those actions were effective, i.e., did the pain persist, recur, or go away?

Document the client, family member or significant other’s actual response (verbal or non-verbal) to any aspect of care provided even if you were not the one providing it. Doing so indicates that you have evaluated the results of care. It is perfectly acceptable to chart the client’s verbal responses in the record as long as you use quotation (“) marks. Non-verbal responses should be described in as much detail as possible.

Make sure your documentation reflects the nursing process and your professional capabilities. Chart completely, concisely and accurately (“Tell it like it is.”). Write clear sentences that get right to the point. Use simple, precise words. Don’t be afraid to use the word “I.”

Be sure to record your full name, credentials and job title in the required section on documentation forms. Some forms will ask you to record your initials as well. Your signature must be in cursive writing so a word of final caution: do take the time to sign your name legibly.

Beyond The Basics

Client Education and Instruction: Other information that needs to be recorded in the medical record includes any education or instructions you give to the client, his family or significant other. Anytime there is a new medication or treatment the client, family member and other personnel must be educated and informed. Documentation of these actions is required. Include the fact that you informed the client/caregiver of the new order; chart the education of dosage, actions, side effects and schedule; chart that you made changes on the medication administration record or task sheets (if applicable); chart how you were able to communicate the new orders to other nursing personnel responsible for the client’s care, document your communications regarding the new orders to the office.

Check Off Sheets: In some instances a pre-printed, standardized check off form may be used where all you have to do is check off or initial what you have done. The only time you may have to write any notes is when something is specific or unique to this particular client, something that can’t be included on a standardized check off form. Remember: if you do not check off items, it means that legally the care was not done.

Phone Calls: We don’t often think about phone calls, but they can contain certain information for which we have obligations such as advice that we may give to a client or a phone order that we may take from a doctor. To protect yourself in these kinds of phone conversations, a detailed summary of your conversations is charted in the client record.

Details of each call should include:

  1. Date and time of the call
  2. Caller’s name, position or credentials, call back phone number and address
  3. Reason for the call, request, complaint
  4. Your response to the call, advice you gave, protocol you followed (if applicable)
  5. Others that you notified as a result of the call
  6. Your name and credentials
  7. If taking doctor’s orders, transcription of the orders word for word and documentation that you read the orders back for verification.

More Do’s to Make Charting Successful

  • Chart as soon as possible after giving care; don’t wait to chart until the end of your work day. Chart often enough to tell the whole story.
  • If you remember an important point after you’ve completed your documentation, chart the information with a notation that it’s a “late entry.” Include the date and time of the late entry.
  • Chart all of the details relating to visits by physicians or other members of the health care team such as the teacher, therapist, case worker, dietician, social worker, etc. Describe the purpose of the visit, the name of the visitor, the time spent with the client and the outcome of the visit.
  • If you don’t give a medication, circle the time and document the reason for the omission.
  • If information on a form such as a flow sheet doesn’t apply to your client, write NA (not applicable) in the space provided.
  • Use only commonly used or approved abbreviations and symbols. Refer to the procedure manual for a list of approved abbreviations. When in doubt spell out the words. Remember many medications have similar names but very different actions.
  • When documentation continues from one page to the next, sign the bottom of the first page. At the top of the next page, write the date, time and “continued from previous page.” Make sure each page contains the client’s identifying information, date and year.
  • Re-read your documentation. You need to paint a picture of the client. Pretend you know nothing about the client. Then read your notes and see if your notes are capable of making you see the client as he/she really is.

See part I HERE and part II HERE.

 

 

The Most Important Document

Charting

Home Healthcare Documents
Form CMS-485 (Plan of Care)
“The Most Important Document”

Home Health is known for its plethora of documents, but one form stands out amongst them all: the “Plan of Care” also called the “485” after its Center for Medicare/Medicaid Services document No. CMS- 485.

This document is so important because it is the so called “Mother Document.” Plans of Care combine the orders of multiple medical disciplines into one document. This comprehensive authoritative Document governs many of the forms in the home chart and the actions of the nurses providing care. Each 485 contains the Patient and Provider demographics, Medication orders, Nursing orders, Diagnosis/Procedure Codes, Supply lists, Nutritional requirements, Allergy info, Patient Activities/Limitations, Ancillary care orders (OT,PT, etc.), Goals and Discharge plans, and a Penalty statement for falsification, misrepresentation or concealment of essential information on the form.

According to CMS rules the Patient must be evaluated and the Nurses supervised and orders rewritten at least every sixty days. All Therapies and medications listed become Doctors Orders once signed. All other documents (i.e., Medication Administration Record) in the home chart should follow the orders listed on the 485, except interim orders written/signed after the date of the 485. The 485 should be the “Go To” document when unsure, or verification of Rx/Tx’s is needed.

Keeping the 485 updated and accurate, is the responsibility of all Care Providers utilizing it as a fiduciary document to authorize their professional services. The 485 is edited by the Nursing Supervisor and endorsed by the Doctor every 60 days, but in-between that period the plan is adjusted and tuned to match the Patients dynamic condition. Medications are changed, diets are adjusted or therapies may be started. When these interim alterations occur, it is each caregiver’s responsibility to verify if needed and pass on to the Nursing Supervisor proof of such changes in a timely manner so the 485 will be accurate the next certification period. Verification can be done via phone calls/faxes and Verbal/Telephone (VO/TO) orders forms. Clear, timely and accurate communication is the best prophylactic therapy professional caregivers can administer. Consistently checking the 485 and interim orders w/ timely communication is the bridge to good continuity of care. All interim order copies should be kept with or near the 485 for reconciliation by all caregivers.

Utilizing and maintaining the Plan of Care CMS- 485 is serious business, not to be taken lightly. Let me quote the responsibilities charged in the Illinois Nurse Practice Act: “The administration of medications and treatments as prescribed by Physician…a Dentist…Podiatrist…Optometrist…PA…APN. The coordination and management of the Nursing Plan of Care.”

Please pay attention to this important document and communicate with your Nursing Supervisor. Your Patient, his/her PMD and your fellow caregivers will love you for it.

by Shawn A. Pickett, MSN, RN

First published on American Home Health's Newsletter, December 2008.

 

Documentation, Standards & Liability Part II

Nurse Charting

In Part I we discussed what may constitute a malpractice claim against a nurse. The main point to be made in this article is to convince you to maintain a current working knowledge of nursing law, standards, policies and procedures and to document the care you provide in order to prove that you provided care which would be considered “good and accepted practice.”

The significance of medical records is both scientific and legal. As a record of illness and treatment, it saves duplication in future cases and it helps in immediate treatment. There should be thorough documentation. Documentation of patient care may not be nurses’ favorite activity; however, nurses who find themselves involved in lawsuits and have documented thoroughly will thank themselves later. Charting is almost certainly the most essential facet of proving that nurses have met the standards of care. The nurses’ notes are aids to medical diagnosis and in understanding the patient’s behavior. In addition, it serves as a legal protection for the facility, doctor, and nurse by reflecting the disease or condition of the patient and its management. Proper documentation reflects the quality of care that you give to your clients and is evidence that you acted as required or ordered. Healthcare providers must comply with established standards of care. Standards of care arise from many different sources:

  1. Regulations based on state and federal legislation or statutes.  Regardless of the term used, they are the law.
  2. State Nurse Practice Act
  3. Practice guidelines
  4. Employer’s policies and procedures
  5. Expert witnesses

When dealing with statutes and regulations, it is important to understand those in your own state. Violating any one of them would make you automatically negligent (not exercising the degree of care that a person of like training and experience would do under the same or similar circumstances) without the right to defend yourself. On the brighter side, proof of your compliance to any particular statute or regulation can be used in your defense to show that you did follow a standard of care.

Practice guidelines and agency policies and procedures are not laws. Failure to follow them does not mean that you are automatically negligent. What it does mean is that it will be up to a jury to decide whether or not you were negligent. Practice guidelines and agency policies and procedures are often introduced as standards of care by a prosecuting attorney trying to prove that negligence has occurred. On the other hand, a defense attorney will use the same guidelines and policies/procedures as evidence that standards of care were met.

Expert witnesses are used by both prosecuting and defense attorneys to establish standards of care. Depending on the kind of legal case, an expert witness could be a nurse, a doctor, a facility administrator, etc. They are usually individuals who are well known and respected in their field. An expert’s role is to explain to the jury the standard of care based upon their particular area of expertise. They are allowed to use articles, practice guidelines, policies, etc. to prove their point. The jury will interpret the opinions of the expert witnesses and determine for themselves if negligence has occurred.

Although your employer should periodically update their policies and procedures and keep you informed about new or revised standards of care and/or state legislation, it is still your responsibility to get that information for yourself so that you can minimize your risk of liability.

Along with keeping yourself informed, it is also critical that you value doing complete and accurate documentation in the medical record as yet another means of avoiding liability. It is well known that the medical record can change the entire climate surrounding a lawsuit. In fact, medical records, in themselves, may be the very source of a lawsuit. Not only is complete and accurate documentation a means of telling the story of a client’s health care history over time, but it is also often required to justify reimbursement of services that are provided to a client. When that reimbursement is coming from programs like Medicare and Medicaid, denial of those funds would certainly be a critical situation in agencies caring for the elderly and/or the poor.

Failure to document or faulty documentation on your part is risky behavior that should be avoided. Knowing that, it is highly suggested that you obtain a copy of the documentation standard (policy) where you are employed and become very familiar with it. Questions you may have can be directed to either your immediate supervisor or a member of the education department in your agency.

Above all, the best way for the nurse to avoid a lawsuit is to be aware of the standards of nursing practice and follow them by heart. Ultimately, to prevent errors, nurses should meet the standards of care. It also implies that a nurse should be aware of their employer’s policies and procedures, the state nursing practice act, and the professional standards of his specialty. Ergo, nurses should exercise their sound verdict and employ standards of nursing care in order to avert lawsuits or to protect themselves.

See part I HERE.

Part III of this article coming soon…

PREDICTING THE FUTURE – Nursing Talk

Nursing Talk

Dear Cassandra,

When I went to high school in the 1970’s, I took college prep courses. I excelled in math and science and took algebra, calculus, geometry, and even Fortran (a computer programming language). My career goal was business.

At that time, college prep students did not take typing. Typing was part of the secretarial/clerical track including shorthand.

Instead, I became a nurse. The result is that I am a 48 year old nurse with no keyboarding skills or computer skills. Do you think home health documentation will be done on computers during my working career?

Clueless about Computers

*******************************************

Dear Clueless,

The technological advances made during our lifetime have been phenomenal. Many farm families in Illinois did not even have electricity until 1947. Th at was a result of the Rural Electrification Act of 1936, a federal program aimed at bringing electricity to farms, ranches, and other rural areas across the nation. In the 1950’s, lucky Chicago families sat across their living rooms staring at tiny black and white TVs, and they invited their neighbors and relatives to come watch this wonderful invention. Until the 1970’s, the workers at the Chicago offi ce of the Burlington Northern were calculating tariff s for cross-country freight by hand using pen and paper. Many suburban elementary schools got their first computers in the 1980’s. Your nieces and nephews with their cell phones and iPods cannot comprehend these things.

Today most hospitals and large clinics have medical records on the computer. However, the transfer of electronic medical fi les is not seamless. How many times have you gone for pre-op tests at the hospital and your surgeon tells you he has not received the results? The American Reinvestment and Recovery Act of 2009 (Stimulus Bill) dedicated more than $20 billion to develop a nationwide electronic health records exchange by 2014. On February 12, 2010, former Governor Pat Quinn announced that Illinois was to receive $18.8 million in federal funds to develop a statewide Health Information Exchange, which was to allow Illinois healthcare providers to electronically share health information.

In Greek mythology, Apollo, the god of love, gave Cassandra the gift of prophecy. However, when she did not return his love, he placed a curse on her so that no one would ever believe her predictions. I hope you do believe the prediction of this Cassandra.

Yes, Clueless, I do believe home health documentation will be done on computer during your working career. In fact, I believe it will happen within the next fi ve years. Th e Visiting Nurses Association in Aurora requires their home health nurses to come to the Aurora offi ce to use banks of computers to enter their clinical notes.Another company issues a laptop to each home health nurse for the nurse to use to “do paperwork” in the home.

This transition to computer technology is not going to be cheap. Th e cost of the hardware alone (e.g., a laptop computer for each nurse) will be substantial. Add to that the yearly contract with the on-line fi rm, the training and workforce development costs, added insurance costs, IT (Information Technology) support, replacement hardware, and other expenses.

You need to become computer literate. You don’t need to know how to program a computer. You need to know how to turn it on and use it. Take a basic computer class at your community college. Go to the library to use the computers.
Enlist your nieces and nephews to teach you. Start now. Don’t wait until your job depends on your being computer literate.

If you have little or no keyboarding skills, get the program Mavis Beacon Teaches Typing. Th e program uses games to teach keyboarding skills. No more typing boring paragraphs for three minutes! You have the nursing skills. I know you can master the computer.

Cassandra

Note: First published on American Home Health's news, December 2010.

Documentation, Standards & Liability Part I

Nurse Charting

The expanded role of nurses and the increasing demands placed on them have led to an expansion of legal liability for malpractice. Historically, liability fell upon physicians, and the nurses were largely considered an administrative arm of the physician. However, the nurse’s responsibilities of patient care management have opened new doors for legal claims against nurses.

What Constitutes Malpractice?

  1. Not all unexpected, unintended, or even undesired medical results can be attributed to the fault of the healthcare provider. A patient must prove four elements to establish a malpractice case.
  2. There must be a nurse-patient relationship. It is out of the nurse-patient relationship that a nurse’s duty to the patient arises.
  3. The patient must establish the scope of the duty that was owed by the nurse; this is usually done though an expert witness testifying about the care that was required.
  4. There must be a departure from “good and accepted practice.” Good and accepted practice is most often defined as care that would have been provided by the ordinarily prudent nurse practicing in the particular circumstances.
  5. It must be shown that the injury was caused by the act or acts that departed from accepted nursing care. It must be proved that if the nurse had not been negligent, then more likely than not, the patient would not have suffered harm.

What Events Commonly Result in Malpractice Cases?

The primary causes of litigation arising from medication errors are wrong dose given, wrong drug administered, incorrect method of administration, and failure to assess for side effects and toxicity.

Another common cause is the failure to properly monitor and assess the patient’s condition and failure to properly supervise a patient resulting in harm. Typically, negligent monitoring cases arise from a nurse’s failure to perform an assessment and notify the treating physician of changes.

The need to advocate on behalf of a patient when the suitability of care is at issue is also a common allegation. In many instances, merely carrying out a physician’s order may insulate a nurse from liability. However, it is well established that such orders will not insulate the nurse when the orders are questionable. Therefore, a nurse has an obligation to advocate on behalf of the patient when issues arise about the course of care or treatment being provided. The issue in these cases arises from the nurse’s duty to keep the patient safe.

How to Decrease Your Risk of a Liability Claim

Utilizing the nursing process and employing critical thinking may decrease bad outcomes that commonly lead to malpractice claims. The steps of the nursing process are described as follows:

  1. Assessment;
  2. Problem/need identification;
  3. Planning;
  4. Implementation;
  5. Evaluation.

By ensuring that each step is taken and that reflection is given by using critical thinking, the likelihood of an avoidable adverse medical event occurring is less likely. In medication administration, the 5 Rs are often cited: right patient, right drug, right route, right dose, and right time. All too often one or more of these “rights” are violated, and a patient is injured. As with any order, guideline, directive, or principle within the nursing process, following these steps is only the beginning. To ensure that the clinical circumstances warrant implementation of the order, critical thinking is essential when administering any drug.

Why is Documentation so Important?

At trial, each party presents evidence, including testimony of witnesses, in an effort to prove their position. The jury then deliberates and determines the facts based on what they believe most likely happened. The jury then applies the law and decides whether the facts, as they have determined them to be, create liability.

In negligence cases, discrepancies include disputes over symptoms complained of, signs that did or did not exist, and care or treatment that was recommended and/or provided. In an effort to determine the facts, the jury will study the medical record. Each record is unique in that it is usually created at a time when there is no interest in a legal outcome. The difficulty will lie in proving that something was done when a patient’s attorney is suggesting that it wasn’t and there is no supporting documentation.

The question on the minds of the jury will be if there is no documentation, did the nurse actually perform according to nursing standards. Your credibility will most certainly be in question if you said you did perform according to standards but did not document your actions. After all, you have already proven that you don’t always perform according to nursing standards because you did not document all your actions. Without such documentation, it then becomes the task of the jury to determine the nurse’s credibility, and draw inference from the existing documentation.

Conclusion

For nurses, the chance of being named in a malpractice lawsuit remains relatively small. However, the risk clearly is increasing. Utilizing good nursing care and employing critical thinking will significantly decrease the likelihood of being named in a malpractice lawsuit. Your skill combined with good documentation technique is the best way to avoid an adverse legal outcome in the event that you are sued.

Part II of this article coming soon…