♦ The type of nursing information that appears in a medical record isn’t dictated by standards set by the courts. It’s governed by standards developed over the years by the nursing profession and by state laws.

♦ Documentation that meets these standards communicates the patient’s status, medical treatment, and nursing care.

♦ Professional organizations such as the American Nurses Association (ANA) and regulatory agencies, such as The Joint Commission and the Centers for Medicare and Medicaid Services (CMS), have established that documentation must include ongoing data collection, interventions made, patient teaching, responses to therapy, and relevant statements made by the patient.

♦ Although documentation goals have changed little since their inception, documentation methods have changed dramatically.

– For example, nurses no longer need to spend valuable time writing long narrative notes. Instead, many facilities today use such methods as flow sheets, graphic records, checklists, and charting by exception (in which only exceptions from articulated standards of care are charted).

– While flow sheets save valuable nursing time, they’ve been criticized as being too abbreviated and lacking important narrative information about the patient’s condition. If used prudently, however, flow sheets can trigger or remind a nurse what actions are indicated.

♦ Errors and omissions can severely undermine your credibility in court.

– A jury could reasonably conclude that you didn’t perform a function if it wasn’t charted.

– If you failed to chart something and need to enter a late entry, date it the day you entered it.

♦ In the case of Anonymous v. Anonymous, Suffolk Superior Court, Boston (1993), failure to chart led to a $1 million settlement.

– A 2-year-old was admitted to Children’s Hospital for correction of a congenital urinary defect.

– Postoperative orders required blood pressure, pulse, and temperature readings to be taken every 4 hours, and respiratory rate and reaction to analgesia every hour.

– The child’s care wasn’t charted for 5 hours.

– The child was found in cardiorespiratory arrest and died from an overdose of an opioid infusion.

– The responsible nurse admitted failing to assess the child strictly according to the orders; she also claimed that she had assessed the child adequately but had been “too busy” to chart her observations.

♦ Failure to comply with a facility’s policy can constitute an omission.

– In Wallace v. Sacred Heart Hospital, Escambia County, Florida (1997), a nurse failed to apply Posey restraints to a patient who had a history of stroke and seizure disorder and was at high risk for falls.

– Early one morning, the patient was discovered trying to walk to the bathroom.

– A nurse found her and assisted her back to bed but neglected to apply physician-ordered restraints.

– One hour later, the patient was found on the floor with a fractured left hip.

– The nurses involved failed to follow the facility’s policy for patients at high risk for falls and the physician’s order for restraints.

– A confidential settlement was reached during mediation.

♦ The purpose of charting is communication, with an emphasis on timeliness.

♦ When the patient’s condition deteriorates or changes in therapy are clearly indicated, you must not only chart this information but also contact the physician as soon as possible and chart the fact that you contacted the physician, the time the contact was made, and the physician’s response.

♦ If the physician isn’t responding appropriately in your opinion, you must contact the next individual in the chain of command. Failure to do so is a breach of duty to the patient and leaves you vulnerable to a malpractice lawsuit.

♦ There are numerous legal cases involving failure of a nurse to notify a physician of changes in the patient’s condition. When such notification isn’t documented, it’s nearly impossible to prove that the physician was called in a timely manner and that all critical information was communicated. These cases are often extremely serious, resulting in death or permanent disability.

♦ In a California case, Malovec v. Santa Monica Hospital, Los Angeles County, California Superior Court, Case No. SC 019-167 (1994), a woman in labor repeatedly asked the charge nurse to call the chief of obstetrics because her obstetrician refused to perform a cesarean delivery despite guarded fetal heart tracings. The charge nurse refused, and the baby was born with cerebral palsy and spastic quadriplegia. A confidential settlement was reached.

♦ Any needed corrections to the medical record should be made only by drawing a line through the initial charting, signing it, and dating it. Then you can proceed to supply the proper entry.

♦ Change an electronic record through an “edit” entry; these are traceable.

Never erase, obliterate, or otherwise alter a record.

♦ Completely defensible malpractice cases have been lost because of chart alterations. The jury simply concluded the nurse was covering up something.

♦ Never try to make the record “better” after you learn a malpractice case
has been filed. Attorneys have methods for analyzing papers and inks and can easily detect discrepancies.