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DOCUMENTATIONAs a Loss Prevention
Technique
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Today’s 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.
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Legal Perspective on Documentation
• Not documented, not done.
• Poorly documented, poorly done.
• Incorrectly documented, fraudulent.
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Quality Documentation is Quality Care
• Structured writing typically inspires structured performance.
• Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
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You 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.
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The 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.
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Basis for Reimbursement
Your documentation may
influence how you and your
employer are reimbursed for
services rendered and
minimize financial loss.
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Considerations for Quality Documentation
Contemporaneous documentation
Accurate documentation
Fraudulent documentation
Inappropriate documentation
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Documentation as a Loss Prevention Technique
• Documentation Dos and Don’ts:
• 10 Risk Management Strategies
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Risk Management Strategy 1
Do not erase.
Do not use “white out”.
Do not cross out an error with more than one line.
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Risk Management Strategy 2
Record only the facts.Document only observed
behavior.Document healthcare services
rendered.
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Risk Management Strategy 3
Do not write critical comments.
Do not document your opinions.
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Risk Management Strategy 4
Begin each entry with the date and time and end each entry with signature and
title.
Example:
(03/31/09 - 7:50AM - Jane Doe, BCCNS)
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Risk Management Strategy 5
Do not leave blank spaces.
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Risk Management Strategy 6
Record all entries legibly and in ink.
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Risk Management Strategy 7
Avoid generalized phrases such as "bed soaked" or "a large
amount."
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Risk Management Strategy 8
If an order is questioned, document that clarification was sought and discussed.
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Risk Management Strategy 9
Document only your own observations and patient
services rendered.
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Risk Management Strategy 10
Do not permit any visiting relative or other third-party access to the patient care
record.
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Communication Challenges
Attributes:» Factual» Accurate» Current» Confidential
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Reporting Challenges
Oral Report – Typically, conducted at change
of shift.
Documentation/Written Report – Completed during shift.
Nurses must communicate information about patients to other nurses and other health care workers.
Documentation Techniques
Strengths and Weaknesses
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Documentation Methods
• Charting by Exception
• FOCUS
• Narrative
• SOAP
• Electronic
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• Charting by Exception
Documentation Methods
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Documentation Methods
• FOCUS
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Documentation Methods
• Narrative
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Documentation Methods
• SOAP
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Documentation Methods
• SOAP (SOOOAAP)
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Documentation Methods
• Electronic
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Effective Risk Management Strategies
• Comply with Nurse Practice Act
• Practice Competent Nursing
• Comply with Policies and Procedures
• Follow Appropriate Incident Reporting
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Incident Reporting
Losses can be reduced by a
timely, prudent, and
compassionate response to an
incident!
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Learn Your Organization’s Guidelines
Examples of Reportable Incidents
• Patient falls
• Medication errors
• Equipment failure
• Complaint by patient, family, visitor
• Treatment-related injuries
• Missed/incorrect diagnosis
• Employee exposures
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BE ALERT! Report unusual occurrences
Document ONLY the facts
• Report immediately, i.e., within 24 hours.
• Do not speculate.
• Do not draw conclusions.
• Do not document impressions.
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QUALITY MONITORING
• Participate in investigations.
• Maintain confidentiality of all information.
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Open 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 timeMay raise patient queries
regarding the healthcare delivered
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Documentation Examples
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Documentation Bloopers
• “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.”
• “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 END