If you use electronic documentation, there is a very good chance that your visits have not been portrayed accurately. Recently, I read a chart where the following notation was on every single visit.
According to the above, the patient had normal genitalia as reported by her or her caregiver or both. How did that go? Did the nurse ask the patient who was a woman how her vagina was looking or did the caregiver spontaneously offer that information to the nurse? There was no reason to assess the external genitalia every visit in a patient who was being seen for hypertension and had no secondary diagnoses that would involve her vagina. If I believed for a minute that this note was accurate I would be gravely concerned about the nurse.
I use this example because when you spend a few minutes imagining all the possibilities, it is as funny as anything I have ever read in a chart. The same error – failing to delete prior documentation or hand writing out of habit occurs everyday in most charts.
A nurse documented that a patient had a flu vaccine every week for 8 weeks. I see notes where the weight does not change even one pound for 4 months. It is rare that I see a heart murmur or extra sound documented even though a patient may have a stenotic valve or heart failure.
This is a problem, folks. For you it is a problem, that is. For me, it is job security. For lawyers, it is gravy.
Included in the top ten list of reasons why nurses are sued for Malpractice are diagnosis failures and delayed treatment. Since nurses do not diagnose or prescribe treatment for illnesses, the only role they could play in diagnosis failures or delayed treatment is failing to communicate effectively. Remember, above all, documentation is the way that nurses and therapists communicate with other caregivers.
So, we know the vaginal status checks and frequent flu vaccine administration are documentation mishaps. What effect does that have on the rest of your documentation? A vicious malpractice attorney with even mediocre skills could discredit everything you have ever written.
You might expect the following questions to be asked during a deposition.
- Would you agree that all patients should have a care plan designed for their unique needs?
- Is it your policy to notify the physician when the condition of the patient changes?
- Would you agree that in order to take care of a patient, accurate documentation is required?
- What condition did the patient have that required a weekly flu shot?
- You charted that the patient had a weekly flu shot and now we know they didn’t. When you charted that you called the MD, was that also a mistake?
This type of error is not limited to computerized documentation. Many nurses repeatedly check the same answer on every OASIS assessment they do for certain data points. Jeff Lewis used to call these ‘favorite answers’. In reviewing data for all nurses in an agency, there will always be one who checks that all of their patients are visually impaired and one that checks that none of them are. Again, this is gravy for a malpractice attorney.
Question: Does your patient ever prefill their own med planner?
Question: Did you ever attempt to find someone else to fill her pill planner?
Answer: No. She was able to do it herself.
Question: Your assessment indicates that Ms. Smith was unable to read medication labels or newsprint and you failed to find someone else to fill her med planner. Were you aware that Coumadin could cause fatal complications if taken incorrectly?
Imagine trying to come up with an answer for that question.
Our lesson for the day is knowing what is not written is as important as what is written. Go practice.
Good article. Yes there are frustrations in computer charting. I find we are often sort of locked in a box and cannot accurately describe an assessment finding, except with a narrative note. The wound assessment documentation is an area that is a problem. It seems the only wounds that fit most of the characteristics would be decubitus. In other words it is not easy to document characteristics of a raised, rough, thickened lesion that has partially torn away at the base. The choices we are given often don’t work, so a narrative it must be. Thanks P.S. Then you hope someone reads the narrative!