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ILLEGAL ALTERATION OF A MEDICAL RECORD
As a general rule, the medical record is presumed to be accurate if there is no evidence of fraud or tampering. Tampering or illegal alteration of a medical record includes adding to someone else’s note, destroying the patient’s chart, not recording important details, recording false information, writing an incorrect date or time, adding to previous notes without marking the entry as being late, and rewriting notes. Evidence of tampering can cause the medical record to be ruled inadmissible as evidence in court.
ACCUCHARTDOCUMENTING AN ALTERED MEDICAL RECORD ON THE INCIDENT REPORT
If the nurse discovers that a medical record has been altered, the nurse should document the findings in an incident report.
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LEGAL CASEBOOKREWRITING RECORDS
In Thor v. Boska (1974), a rewritten copy of a patient’s record was suspected of being an altered record. This lawsuit involved a woman who had seen her health care provider several times because of a breast lump. Each time, the health care provider examined her and made a record of her visit. After 2 years, the woman sought a second opinion and learned that she had breast cancer. She sued her first health care provider. Rather than producing his records in court, the health care provider brought copies of the records and said he had copied the originals for legibility. The court reasoned that he was withholding evidence and held in favor of the plaintiff. Electronic health records document the health care provider’s entered data at the time of patient care in a permanent manner. EHR documents are permanently stored in a digital format by the institution and readily retrievable by subpoena.
Electronic health records (EHRs) track the date and time of data entry and the identity of the user who is logged in. To prevent use by another party that would be recorded under the health care provider’s log-in identifiers, the provider should be sure to keep all usernames and passwords private and log out of the computer whenever it is left unattended. See Rewriting records above.
Essential Documentation
The nurse should record the date and time that the incident report was completed. Write a factual account of what was observed in the medical record or the conversations with the colleague asking for alterations in the record. Include the names and titles of persons notified.
See Documenting an altered medical record on the incident report, page 193, for how to report an altered medical record.
IMPLANTED PORT, ACCESSING
Surgically implanted under local anesthesia by a health care provider, an implanted port consists of a silicone catheter attached to a reservoir, which is covered with a self-sealing silicone rubber septum. It is used most commonly when an external central venous access device is not desirable for long-term intravenous (IV) therapy. Typically, implanted ports deliver intermittent infusions. They are used to deliver chemotherapy and other drugs, IV fluids, and blood. They can also be used to obtain blood.
To access an implanted port, a noncoring or Huber needle is attached to an extension set, flushed with normal saline solution,
and inserted into the reservoir. After checking for blood return, the implanted port is flushed with normal saline solution, according to the facility’s policy. Consider adding a heparin flush to maintain line patency.
and inserted into the reservoir. After checking for blood return, the implanted port is flushed with normal saline solution, according to the facility’s policy. Consider adding a heparin flush to maintain line patency.
While the patient is hospitalized, a Luer-lock injection cap may be attached to the end of an extension set to provide ready access for intermittent infusions. In addition to saving time, a Luer-lock cap reduces the discomfort of accessing the implanted port and prolongs the life of the implanted port septum by decreasing the number of needle punctures.
Essential Documentation
An EHR or flow sheet should note the date and time that the implanted port was accessed. Within the EHR or flow sheet, the nurse should note whether signs or symptoms of infection or skin breakdown are present. Describe any pain or discomfort that the patient experienced when the implanted port was accessed. If nursing interventions included ice or local anesthetic, make sure to chart it. Describe how the area was cleaned before accessing the implanted port. Note whether resistance was met when inserting the needle and whether a blood return was obtained. Include the number of attempts made to access the implanted port. Record any problems with the normal saline flush, such as swelling or pain. Chart the time that the health care provider was notified of any problems, any orders given, nursing interventions, and the patient’s response. Also, document the patient education provided.
Accessing an Implanted Port
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IMPLANTED PORT, CARE OF
After insertion of an implanted port, the nurse should monitor the site for signs of hematoma and bleeding. Edema and tenderness may persist for about 72 hours. The incision site requires routine postoperative care for 7 to 10 days. The nurse should assess the implantation site for signs of infection, port rotation, and skin erosion. Depending on the health care facility’s policy, a dressing may or may not be necessary except during infusions or to maintain an intermittent infusion port.
Patients receiving continuous or prolonged infusions require a dressing and needle change every 7 days. The nurse will also change the tubing and IV solution for long-term central venous infusion according to facility policy. After a bolus injection or at the end of an infusion, flush the implanted port with normal saline solution followed by heparin, according to the facility’s policy. For a patient receiving an intermittent infusion, the implanted port should be flushed periodically with heparin solution. When the implanted port isn’t being used, it should be flushed every 4 weeks. During the course of therapy, the nurse may need to clear a clotted implanted port with a fibrinolytic drug, as ordered.
Essential Documentation
Within the EHR, the nurse should enter the date and time. Also note the appearance of the site, bleeding, edema, or hematoma. Document any sign of skin infection or device rotation. Indicate the type of therapy that the patient is receiving, such as continuous infusion or intermittent therapy. Document normal saline solution and heparin flushes as well as measures taken to maintain a patent infusion. Record all dressing, needle, and tubing changes.
Care of Implanted Port
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IMPLANTED PORT, WITHDRAWING ACCESS
When the nurse is caring for a patient with an implanted port, the nurse will need to remove the noncoring Huber needle every 7 days (according to facility policy) or at the end of therapy. After the dressing is removed, attach a 10-mL syringe containing normal saline solution (according to facility policy), aspirate for blood, then flush the catheter. Follow this with a heparin flush according to facility policy. The extension tubing should then be reclamped to maintain positive forward flow. The nurse should stabilize the implanted port with the nondominant thumb and forefinger while gently pulling the needle upward. Protective devices are available to prevent a rebound needlestick. Discard the needle in the appropriate container. Apply adhesive dressing to the site according to facility policy.
Essential Documentation
The EHR will enter the date and time that access is withdrawn from the implanted port. The nurse should note that the procedure was explained to the patient. Document the solutions, amounts, and size of the syringes used to flush the extension tubing. The solutions and their volumes are typically recorded in the medication administration record (MAR) of the EHR; A flow sheet should also note whether blood was aspirated or resistance was met. Record that the needle was removed, noting any clots on the needle tip. Describe the condition of the site and the type of dressing applied.
Withdrawing Access to Implanted Port
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INAPPROPRIATE COMMENT IN THE MEDICAL RECORD
Negative language and inappropriate information should not be included in a medical record. Such comments are unprofessional and can also trigger difficulties in legal cases. A lawyer may use negative or inappropriate comments to show that a patient received poor care. (See Unprofessional documentation below.)
Essential Documentation
Documentation in the medical record should contain descriptive, objective information: what the nurse sees, hears, feels, smells, measures, and counts. The nurse should not suppose, infer, conclude, or assume. Describe events or behaviors objectively, and avoid labeling them with such expressions as “bizarre,” “spaced out,” or “obnoxious.” (See Charting objectively, page 199.)
The following note is an example of a nurse using inappropriate words with negative connotations:
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The next note concerns the same situation, but it is written objectively:
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LEGAL CASEBOOKUNPROFESSIONAL DOCUMENTATION
Negative language and inappropriate information should not be included in a medical record and can be used against the nurse in a lawsuit. For example, one elderly patient’s family became upset after the patient developed pressure ulcers. They complained that the patient wasn’t receiving adequate care. The patient later died of natural causes.
However, because the patient’s family was dissatisfied with the care that the patient received, they sued. In the patient’s chart, under prognosis, the health care provider had written “PBBB.” After learning that this stood for “pine box by bedside,” the insurance company was only too happy to settle for a significant sum.
CHARTING OBJECTIVELY
What the nurse says and how that message is relayed are of utmost importance in documentation. Keeping the patient’s chart free from negative, inappropriate information can be quite a challenge when writing detailed narrative notes. Here are some guidelines to help the nurse sidestep charting pitfalls and record an accurate account of the patient’s care and status.
Avoid Reporting Staffing Problems
Even though staff shortages may affect patient care or contribute to an incident, staffing problems should not be included in a patient’s chart. Instead, discuss them in a forum that can help resolve the problem. In a confidential memo or an incident report, call the situation to the attention of the appropriate personnel, such as the nurse manager. Also review the facility’s policy and procedure manuals to determine how employees are expected to handle this situation.
Keep Staff Conflicts and Rivalries out of the Record
Entries about disputes with nursing colleagues (including characterization and criticism of care provided), questions about a health care provider’s treatment decisions, or reports of a colleague’s rude or abusive behavior reflect personality clashes and do not belong in the medical record. They aren’t legitimate concerns about patient care.
As with staffing problems, address concerns about a colleague’s judgment or competence in the appropriate setting. Discuss all facts with the nurse manager. Consult with the health care provider directly if an order is concerning. Share opinions, observations, or reservations about colleagues with the nurse manager only; avoid mentioning them in a patient’s chart.
If personal accusations or charges of incompetence are discovered in a chart, discuss this with the nurse supervisor.
Steer Clear of Words Associated with Errors
Terms such as by mistake, accidentally, somehow, unintentionally, miscalculated, and confusing can be interpreted as admissions of wrongdoing. Instead, let the facts speak for themselves—for example, “Pt. was given Demerol 100 mg I.M. at 1300 hours for abdominal pain. Dr. Jones was notified at 1305 and is on his way here. Pt.’s vital signs are BP 120/82, P 80, RR 20, T 98.4°F.”
If the ordered drug dose was 50 mg, this entry will let other health care providers know that the patient was overmedicated.
Avoid Bias
Don’t use words that suggest a negative attitude toward the patient. For example, do not use unflattering or unprofessional adjectives, such as obstinate, drunk, obnoxious, bizarre, or abusive, to describe the patient’s behavior. If a patient is difficult or uncooperative, document the behavior objectively. Negative words could cause a plaintiff’s attorney to attack the nurse’s professionalism with an argument such as this: “Look at how this nurse felt about my client—the nurse called the patient ‘rude, difficult, and uncooperative.’ No wonder the nurse didn’t take good care of the patient; the nurse didn’t like the patient.”
Don’t Assume
The nurse should always aim to record the facts about a situation, not assumptions or conclusions. The nurse should only record only what is seen and heard. For example, the nurse should not record that a patient pulled out an IV line if it was not witnessed. The nurse should, however, describe findings—for example, “Found pt., arm board, and bed linens covered with blood. IV line and IV catheter were untaped and hanging free.”
INCIDENT REPORT
An incident is an event that’s inconsistent with the facility’s ordinary routine, regardless of whether injury occurs. In most health care facilities, any injury to a patient requires an incident report (also known as an event report or occurrence report). Patient’s complaints, medication errors, and injuries to employees and visitors require incident reports as well.
An incident report serves two main purposes:
to inform hospital administration of the incident so that it can monitor patterns and trends, thereby helping to prevent future similar incidents (risk management)
to alert the administration and the hospital’s insurance company to the possibility of liability claims and the need for further investigation (claims management)
Essential Documentation
When filing an incident report, the nurse should include only the following information:
the exact time and place of the incident
LEGAL CASEBOOKREPORTING AN INCIDENT
Nurses have a duty to report any incident witnessed firsthand. Failure to report an incident has many consequences, including termination and exposure to personal liability for malpractice—especially if failure to report the incident causes injury to a patient.
Failure to document the incident, treatment, follow-up care, and patient’s response may result in the interpretation that the nurse is withholding information. If the case goes to court, the jury may be asked to determine if the patient received appropriate care after the incident.
In the incident report and progress note, the nurse should include any statements made by the patient or the patient’s family concerning their role in the incident. For example, “Patient stated, ‘The nurse told me to ask for help before I went to the bathroom, but I decided to go on my own.’” This kind of statement helps the defense attorney prove that the patient was entirely or partially at fault. If the jury finds that the patient was partially at fault, the concept of contributory negligence may be used to reduce or even eliminate the patient’s recovery of damages.
the names of the persons involved and any witnesses
factual information about what happened and the consequences to the person involved (supply enough information so that the administration can decide whether the matter needs further investigation)
any relevant facts (such as immediate actions in response to the incident—e.g., notifying the patient’s health care provider)
After completing the incident report, the nurse should sign and date it. (See Tips for writing an incident report below.)
See Completing an incident report, page 202, for how to document a patient incident.
TIPS FOR WRITING AN INCIDENT REPORT
When a malpractice lawsuit reached the courtroom in years past, the plaintiff’s attorney wasn’t allowed to see incident reports. Today, in many states, the plaintiff is legally entitled to a record of the incident if he or she requests it through the proper channels.
When writing an incident report, keep in mind the people who may read it, and follow the guidelines given here.
Write Objectively
The nurse should record the details of the incident in objective terms, describing exactly what was seen and heard. For example, unless the nurse actually saw a patient fall, the nurse should document: “Found patient lying on the floor.” Then the nurse should only describe the actions taken to provide care at the scene, such as helping the patient back into bed, assessing the patient for injuries, and calling the health care provider.
Avoid Opinions
Don’t commit opinions to writing in the incident report. Rather, verbally share suggestions or opinions on how an incident may be avoided with the nursing supervisor and risk manager.
Assign No Blame
Do not admit to liability, and do not blame or point the finger at colleagues or administrators. Steer clear of such statements as “Better staffing would have prevented this incident.” State only what happened.
Avoid Hearsay and Assumptions
Each staff member who knows about the incident should write a separate incident report. If one patient is injured in another department, the staff members in that department are responsible for documenting the details of the incident.
File the Report Properly
Consult the facility risk manager or nursing supervisor in writing and filing an incident report.
ACCUCHARTCOMPLETING AN INCIDENT REPORT
When a reportable event is discovered, the nurse must fill out an incident report. Forms vary, but most include the following information.
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INCREASED INTRACRANIAL PRESSURE
The skull is a rigid compartment filled to capacity with three components: brain tissue, blood, and cerebrospinal fluid (CSF). Intracranial pressure (ICP) is the pressure exerted by these three components against the skull. When the volume of one or more of these components increases, the volume of the other two must decrease, or ICP will rise. If increased ICP goes untreated, it can lead to brain herniation and death.
Causes of increased ICP include tumors, abscesses, hemorrhage, head injuries, brain surgery, infection, cerebral infarct, conditions that obstruct venous outflow and cerebral edema.
If increased ICP is suspected, immediately notify the health care provider and ensure adequate airway, breathing, and circulation. Anticipate endotracheal intubation and mechanical ventilation, monitor for changes in level of consciousness (LOC), prepare for ICP monitoring, and anticipate orders for osmotic diuretics.
Essential Documentation
The EHR documents the date and time of the entry. A flow sheet should record the patient’s ICP when on continuous ICP monitoring. The nurse should record assessment findings such as reduced LOC (e.g., confused, restless, agitated, lethargic, or comatose), pupillary changes (including unequal size and sluggish or absent response to light), headache, seizures, focal neurologic signs, increased blood pressure, widened pulse pressure, bradycardia, decorticate or decerebrate posturing, and vomiting. Record the name of the health care provider notified, the time of notification, and the orders given. Document actions taken, such as maintaining a patent airway and ventilation, administering oxygen, administering osmotic diuretics, proper head positioning, and monitoring ICP. Use the appropriate flow sheets to record ICP readings, Glasgow Coma Scale (GCS) scores, intake and output, IV fluids given, drugs administered, and frequent vital signs. Monitor the patient frequently, as ordered, and time and record each assessment. Chart all patient education and emotional support provided.
Increased Intracranial Pressure
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