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Nursing Documentation in the Medical Record

Back to Basics

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WCHOB Case # 1 Newborn Infant Allegation: we failed to properly diagnosis and

treat hypoglycemia Injury: blindness and mild developmental delays Evidence: Parents testified that nursing staff did

not bring infant to mom for regular feedings. There was no documentation in chart regarding feeds. It looked like infant was not fed for 12 hours.

Verdict: Settled out of court

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WCHOB Case #2 Decubitus Allegation: Nursing staff failed to prevent

decubitus of the left heel and knee of 14 yr old receiving epidural pain medication following a urological procedure

Injury: Stage 3 –4 decubitus of the left heel which required skin grafting. Stage 1 decubitus to left knee.

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WCHOB Case #2 Decubitus Evidence: No documentation that the patient was

repositioned every 2 hours while the epidural was running as required in the epidural policy. After decubitus was identified, there was no documentation that the patient was checked or repositioned. Mother testified she never saw a nurse reposition her daughter while the epidural was running.

Verdict: Settled out of court

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WCHOB Case #3 Spinal Injury Allegation: WCHOB failed to recognize and

appreciate the deterioration of the patient’s neurological status and failed to correctly diagnose the spinal fracture

Injury: Paraplegia Evidence: Poor documentation created a very

confusing picture as to when the patient’s neurological deficits were first noted. ED nurses note lacked documentation of any physical assessment by the nurse.

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WCHOB Case #3 Spinal Injury Evidence: Nurses notes indicate in neuro section

that patient had “no response” to lower extremity movement for 2 hours with no intervention by the nurse. Skin assessment section has a “C” documented for cold. This appears to be written over a “W” for warm. (This may not be significant, but it calls into question the integrity of other entries in the chart.) It also appeared that this was charted to agree with the resident’s note that the skin was cold.

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WCHOB Case #3 Spinal Injury Evidence: Nurses notes were timed but not in

order: 7pm- Patient had minimal movement of her toes. Next entry (timed 6:40 pm)- Patient unable to wiggle

toes, does not respond to touch on bottom of feet, legs are floppy. Patient could not initiate any movement.

Next entry (timed 7:30 pm)- Physician in to assess patient

Verdict: Settled out of court

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Purpose of the Medical Record Communication among caregivers about

patient condition, care and response to treatment

Evidence in legal proceedings Reimbursement Data for research studies Planning and implementing quality

improvement measures

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Legal Considerations What catches an attorney’s eye?

Pages without patient identification

Dates and times that don’t correlate with the remainder of the chart

Changes in slant, uniformity, or pressure of handwriting

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Legal Considerations What catches an attorney’s eye?

Changes in ink or pen on the same entry

Erasures or obliterations

Entries written over previous entries to correct or change it

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Common Documentation Errors Omissions

Include all facts needed to provide care to the patient. If it is not documented, you did not do it!

Personal Opinions Record only factual and objective

observations. Include patient statements.

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Common Documentation Errors Vague Entries

Instead of “Patient had a good day”, state why: Patient denied having pain.

Late Entries Identify as late and enter date and time.

Document date and time you are relating back to (04/01/07 for 3/31/07).

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Common Documentation Errors Improper Corrections

As per Kaleida Health Policy MR-16: A single line should be drawn through erroneous information. The individual making the correction should sign, date and time the correction. Do not use correcting fluid. Do not obliterate the original entry.

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Common Documentation Errors Unauthorized Entries

Don’t document for anyone else

Erroneous Abbreviations See next slides See Kaleida Health Policy MR.4 Use of

Abbreviations

Illegibilty and lack of clarity Write so others can read your entry. Use correct

spelling.

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Abbreviation Intended Meaning Error Recommendation

U Units Misread as 0, 4, or cc (e.g. An order for 10 U of insulin can be misread as 100)

Write out “units”

IU International unit Mistaken as IV (intravenous) or 10(ten)

Write ”unit”

QD, QOD Once daily, or once every other day

Mistaken for each other. The period after the Q can be mistaken for an “I” and the “O” can be mistaken for an “I”

Write “daily” or “every other day”

Trailing zero (e.g. 1.0 mg)

1 mg Misread as 10 mg DO NOT USE trailing zeros after a decimal point

Lack of leading zero 0.1 mg (e.g. .1 mg) Misread as 1 mg or 11 mg Always use a zero before a decimal point

MS, MSO4, MgSO4 Morphine Sulfate or Magnesium Sulfate

Misread as the other Write out drug name 

UNSAFE ABBREVIATIONS Updated By JCAHO May 2005

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The following abbreviations are strongly recommended not to be used in medication documentation

BIWTIW

Two times a weekThree times a week

Misread as two or three times a day

Specifically write out “two” or “three times a week”; or write out specific days medication is to be administered (e.g. Q Mon, Wed, Sat)

Ug Mcg Misread as mg, or u misread as 0 units read as grams

Use “mcg” instead

AU, AS, AD Both ears, left ear, right ear

Misread as OU, OS, OD

Specifically write out intended route of administration

OU, OS, OD Both eyes, left eye, right eye

Misread as AU, AS, AD

Specifically write out intended route of administration

X3d For three days Misread as for three doses

Write out “for 3 days”

Practitioners are strongly encouraged to write out all medication names to avoid potential confusion.

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Documentation on the Medication Administration Record

Blue or black ink, unless otherwise specified.

Practitioner’s full legal signature/title must be in the medical record

Corrections as per KH Policy MR.16 Must be placed in patient record upon

discharge

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Documentation on the Medication Administration Record

Scheduled Medications Medication Administration Record Use for all medications given on a continuous basis

PRN Medication Sheet Use for all medications given on a prn basis

Special Medication (STAT) Sheet Use for all STAT, short series, one time only, or pre-

op/test medications

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Pain Documentation Use approved pain scale (CRIES, FACES or

PAINAD) Include: location, intensity, quality,

onset/duration/variation, aggravating or relieving factors

Determine how pain has affected activities Establish a comfort function goal (pain rating that

allows the patient to participate in recovery and quality of life activities)

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Pain Documentation Assess pain as the fifth vital sign, after any

known pain producing procedure, with each new report of pain, and WHEN THE MEDICATION HAS REACHED ITS PEAK EFFECT (IV bolus and PCA – 15-30 minutes, Oral/Rectal – 1-2 hours, IM/SQ – 30 minutes, Epidural or Intrathecal – Fentanyl – 10- 20 minutes; Morphine – 90-120 minutes)

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Pain Documentation Sedation Scale for patients medications

that depress the central nervous system: S = Sleep, easy to arouse 1 = Awake and alert 2 = Slightly drowsy, easily aroused

No action required

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Pain Documentation Sedation Scale for patients medications that

depress the central nervous system:

3 = Frequently drowsy, drifts off to sleep during conversation. Decrease opioid 25 – 50%, consider non-opioid such as acetaminophen or NSAID

4 = Somnolent, minimal or no response to physical stimulation. Consider Naloxone as per Kaleida Health policy CL.9. Notify MD, monitor sedation and respiratory status closely until sedation is less than 3.

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Conclusion Falsifying or altering medical records is a

misdemeanor under some state penal codes. It is also professional misconduct and reportable to the Nursing Board.

Do not write in advance. Document the name of the

physician/resident you spoke to.

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Conclusion Be definite and specific so that information

is clear to any doctor, hospital staff of jury. Five years later at trial, you will not

remember exactly what you meant. Don’t skip lines between entries or leave

spaces. Don’t wait until the end of the shift to

chart. Don’t rely on your memory.

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References Austin, Sally. “Ladies and gentlemen of the jury, I present…the nursing

documentation.” Nursing 2006. 36(1):56-63, January 2006 Wetter, Dana. The Best Defense is a Good Documentation Offense. Corexcel. NCLEX – RN Review Made Incredibly Easy!. 3rd Edition Lippincott, Williams and

Wilkins. Kaleida Health Policy TX.4 Pain Management- Adult/Child Kaleida Health Policy TX.IV’s & Meds.1POL Transcription of Medication Orders and

Use of the Medication Administration Record Kaleida Health Policy TX.IV’s & Meds.2.GDL Guidelines for Completing Scheduled

Medications Medication Administration Record (MAR) Kaleida Health Policy TX. IV’s & Meds.5.GDL Guidelines for Completing Special

Medication Sheet Kaleida Health Policy #GDL_11 Documentation of Adult/Pediatric Patient Care –

Policy Kaleida Health Policy MR.4 Use of Abbreviations Kaleida Health Policy MR.16 Documentation Requirements in the Medical Record