Consistent Medical Charting Combats Claims

Charting a patient’s care is a necessity.

While thorough charting is always appropriate, it becomes vital when a formal complaint is filed with the Patients Compensation Fund.

Charting documents events from the time a patient enters a facility until discharge. It gives others an understanding of why the patient was there, initial and ongoing assessment of the patient’s condition, the care plan and much more.

In a perfect world, defense counsel would request all charting on a patient and assemble a detailed timeline of all care provided. Unfortunately, the process is not always that simple.

Each case must be presented to a three-member medical review panel. During the case’s presentation, the plaintiff spins the details, hoping to seed doubt into the minds of panel members. If a gap in charting occurs, it allows the plaintiff to create this doubt more easily because of the lack of documentation.

Example 1:

The panelists determined there was a Material Issue of Fact against the provider. One lone nurse had routinely documented that the patient was being turned and repositioned according to the schedule provided by the physician. Chart notes were documented at the end of her shift instead of every two hours as required. The other nurses provided no documentation regarding turning and repositioning the patient.

The panel stated that, had all nurses involved in the patient’s care documented turning and repositioning at the end of their shifts, the documentation probably would have been sufficient and enough for the panel to render a favorable opinion.

Defense counsel later learned that none of the panel members believed the outcome of the patient’s care had anything to do with the immediate complaints. However, this belief was not enough to avoid an unfavorable opinion or the resulting litigation.

Example 2:

The case features a patient admitted for cardiac-related complaints. The admitting facility did not require their nurses to enter routine chart notes if a patient was doing well. They did require that vital signs be recorded every four hours, which was completed correctly. The patient was also on telemetry monitors that provided hard data on the patient’s process.

The medical review panel found the facility in question did breach the applicable standard of care solely on the issue of charting. They specifically found that “charting by exception” was the only breach. Charting by exclusion did not affect the ultimate outcome or the patient. Fortunately, no suit was filed following the panel opinion.

A Risk Management Perspective

For nurses, providing patient care by actually interacting and caring for the patient is only half the job. On top of that, nurses are expected to document the care provided, communication with family and physicians, new orders/treatments, follow-ups and any change in the patient’s condition. In a fast-paced environment, accomplishing all of these tasks can become a challenge.

Nursing documentation should be factual, accurate, complete and timely. These tips for improving nursing documentation can help ensure the patient’s story is being told through charting:

• Most organizations chart by exception. This may unintentionally limit the quality and amount of documentation. To prevent a lack of clarity in their charting, nurses are encouraged to conduct and document a head-to-toe assessment of the patient. The examination should take place during their first assessment of the patient at the beginning of their shift or when taking over care of the patient.
• Conducting and documenting the results of the full assessment allows the nurse to establish the patient’s status at the time they took over care. Once the assessment is complete, charting by exception may occur. Exceptions include any change in condition from the nurse’s head-to-toe assessment, rounds, communication with other health care providers, wound care, ADL’s and more.
• Documentation should be objective, not subjective. Document facts and keep personal opinions out of the charting. The nurse is telling the story of the patient, which should not include any personal judgment or bias.
• Charting should be done in as “real-time as possible”. Even the best nurses are unable to provide care and document at the same time. Nurses are encouraged to develop a process to document as soon as possible while the details are fresh in their minds. Doing so limits confusion about what occurred between patients and potentially documenting on the incorrect patient.
• Nurses should be extra careful when they think they are “too busy”. Based on chart reviews, this is the key time when the quality and amount of documentation is noted to be very limited. The busier a nurse is, the higher the risk of not documenting something important. The lack of documentation could ultimately be detrimental to defending a medical malpractice claim.
• Nurses should avoid general statements that can be misconstrued by others. Nurses are encouraged to document the care provided to the patient clearly and in detail.
• Nurses should not rely on their memory. Nurses provide care to hundreds of thousands of patients each year. It is hard to remember every patient or expect that a nurse can remember details about every patient. Timely and detailed charting is a much better solution than relying on memories that may be incomplete or inaccurate.
• When there is any change in the patient’s condition, documentation should include very specific details such as assessments, details of the change in conditions, who was notified of the change, what was discussed, any follow-up orders, how notifications were made (by phone or in-person during rounds), and any other key facts.

In the first claim example, the nurses should have documented all care provided to the patient, including the specific details of basic care such as turning the patient every two hours. While it is a routine practice to turn patients every two hours to prevent skin breakdown, it is extremely important to document that it was done.

The documentation surrounding the second claim example should have contained an assessment of the patient even if the assessment was within normal limits, providing a picture of the patient at the time of the assessment.

Based on the limited documentation provided in both claim examples, there was an increased risk of not meeting the standards of care. Nurses are a key part of telling the patient’s story. As important as caring for the patient is, documentation is just as important because it can provide a safeguard for the nurse and facility in medical malpractice claims.

Learn More

Want more information regarding nursing documentation? Visit our Nursing Process toolkit.