Title: DOCUMENTATION
1DOCUMENTATION
- As a Loss Prevention Technique
2Todays Objective
- Increase awareness of documentation risks,
specifically targeting exposure to negligence and
malpractice claims. - Enhance the quality of documentation by expanding
awareness in order to provide quality patient
care and avoid malpractice incidents. - To address the documentation steps in order to
implement, and thus help protect your patient
from harm and minimize your liability exposure.
3Legal Perspective on Documentation
- Not documented, not done.
- Poorly documented, poorly done.
- Incorrectly documented, fraudulent.
4Quality Documentation is Quality Care
- Structured writing typically inspires structured
performance. - Document the Nursing Process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
5You are what you document
- A well-documented patient care record
- Protects your patient
- Demonstrates to the board of nursing that you are
a competent nurse. - Minimizes the potential of being named as a
defendant in a lawsuit. - Minimizes the potential of a court appearance if
you ARE named in a suit. - Help you win if you go to court.
6The Patient Care Record is a Legal Document.
- Under state laws, the patient care record is the
property of the health care provider. - Patient is entitled to a copy of the record under
the laws of most states. - The record must reflect accurate and
contemporaneous information. - The patient care record documents the care
provided.
7Basis for Reimbursement
- Your documentation may influence how you and your
employer are reimbursed for services rendered and
minimize financial loss.
8Considerations for Quality Documentation
- Contemporaneous documentation
- Accurate documentation
- Fraudulent documentation
- Inappropriate documentation
9Documentation as a Loss Prevention Technique
- Documentation Dos and Donts
- 10 Risk Management Strategies
10Risk Management Strategy 1
- Do not erase.
- Do not use white out.
- Do not cross out an error with more than one line.
11Risk Management Strategy 2
- Record only the facts.
- Document only observed behavior.
- Document healthcare services rendered.
12Risk Management Strategy 3
- Do not write critical comments.
- Do not document your opinions.
13Risk Management Strategy 4
- Begin each entry with the date and time and end
each entry with signature and title. - Example
- (03/31/09 - 750AM - Jane Doe, BCCNS)
14Risk Management Strategy 5
- Do not leave blank spaces.
15Risk Management Strategy 6
- Record all entries legibly and in ink.
16Risk Management Strategy 7
- Avoid generalized phrases such as "bed soaked" or
"a large amount."
17Risk Management Strategy 8
- If an order is questioned, document that
clarification was sought and discussed.
18Risk Management Strategy 9
- Document only your own observations and patient
services rendered.
19Risk Management Strategy 10
- Do not permit any visiting relative or other
third-party access to the patient care record.
20Communication Challenges
- Attributes
- Factual
- Accurate
- Current
- Confidential
21Reporting Challenges
Nurses must communicate information about
patients to other nurses and other health care
workers.
- Oral Report
- Typically, conducted at change of shift.
- Documentation/Written Report
- Completed during shift.
22Documentation Techniques Strengths and Weaknesses
23Documentation Methods
- Charting by Exception
- FOCUS
- Narrative
- SOAP
- Electronic
24Documentation Methods
25Documentation Methods
26Documentation Methods
27Documentation Methods
28Documentation Methods
29Documentation Methods
30Effective Risk Management Strategies
- Comply with Nurse Practice Act
- Practice Competent Nursing
- Comply with Policies and Procedures
- Follow Appropriate Incident Reporting
31Incident Reporting
- Losses can be reduced by a timely, prudent, and
compassionate response to an incident!
32Learn Your Organizations Guidelines
Examples of Reportable Incidents
- Patient falls
- Medication errors
- Equipment failure
- Complaint by patient, family, visitor
- Treatment-related injuries
- Missed/incorrect diagnosis
- Employee exposures
33BE ALERT! Report unusual occurrences
- Report immediately, i.e., within 24 hours.
- Do not speculate.
- Do not draw conclusions.
- Do not document impressions.
34QUALITY MONITORING
- Participate in investigations.
- Maintain confidentiality of all information.
35Open Charting
- Encourages patients to review their own patient
care record - Promotes meticulous documentation by healthcare
providers - Fosters patient inclusion in the healthcare
delivery process - Requires significant time
- May raise patient queries regarding the
healthcare delivered
36Documentation Examples
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44Documentation Bloopers
- Patient had waffles for breakfast and anorexia
for lunch. - She is numb from her toes down.
- While in ER, she was examined, x-rated, and sent
home. - The skin was moist and dry.
- Patient was alert and unresponsive.
- Rectal examination revealed a normal size
thyroid. - She stated that she had been constipated for
most of her life, until she got a divorce. - Skin somewhat pale but present.
- Patient has two teenage children, but no other
abnormalities.
- The patient refused an autopsy.
- The patient has no previous history of
suicides. - Patient has left white blood cells at another
hospital. - On the second day, the knee was better, and on
the third day it disappeared. - The patient has been depressed since she began
seeing me in 1993. - Discharge status Alive but without permission.
- Healthy appearing decrepit 69-year old male,
mentally alert but forgetful.
45THE END