Communication Documentation: The Details Matter

A 68-year-old female presents to the ED with complaints of intermittent abdominal pain for the past week. The ED evaluation produced a diagnosis of pneumoperitoneum with ascites secondary to sigmoid colon perforation with adjacent abscess possibly secondary to generalized ischemic bowel. The ER physician discussed the case with the patient’s PCP and a colorectal surgeon and the patient was admitted to the hospital.

Notes in the patient’s chart read as follows:

6:45 a.m. The nursing note reads, in part, “Patient complains of lower abdominal pain and knee pain…skin mottled to bilateral lower extremities with feet cool to touch. Pedal pulses present. Vital signs stable.”

8:00 a.m. There is a progress note from the colorectal surgeon who states, in part, “1 day history of lower abdominal pain. No GI symptoms. Complains of bilateral lower extremity pain. Abdominal exam benign with no peritonitis. Will have radiologist perform percutaneous drainage.”

His orders at that time address only the abdomen; nothing about the Bilateral Lower Extremity (BLE).

8:30 a.m. The nursing note reads, “Medicated as prescribed for pain – BLE most severe. Right foot pale and cool with mottled legs. Dr. ____ on rounds. Orders noted.”

10:00 a.m. The nurse notes “No change to feet and legs.”

11:30 a.m. The nurse’s note reads, in part, “Darkening mottling to legs from waist down…Called placed to Dr ________ re unable to doppler pedal pulses with legs cool to touch and cold feet.”

At noon, the patient’s PCP arrives, examines the patient and consults a cardiovascular surgeon. The patient is transferred. A CT shows extensive occlusion of the patient’s entire abdominal aorta from the right renal on down to her toes. Her family is told that revascularization of lower extremities not possible due to the length of time of lost blood flow.

The patient expired the next day. The death certificate listed the cause as Sigmoid Colon Perforation with Abscess.

The ED physician, the surgeon and the PCP were named in a malpractice complaint along with the hospital. The Medical Review Panel found that only the hospital breached the appropriate standard of care. The conclusion of the medical review panel was based upon the following:

“(The patient) was seen by Dr. ________ at approximately 8 am, who examined her abdomen and also noted bilateral lower extremity pain. At 8:30 am the nursing staff noted a change in the patient’s condition; her right foot was pale and cool to touch and the patient reported her leg pain was now worse than her abdominal pain. However, the physician was not notified at this change in the patient’s condition. The failure to do so was a breach in the applicable standard of care resulting in a delay in possible treatment and the loss of an opportunity for a better outcome.”

The nurse testified that her note, though entered at 8:30 a.m., was related to the condition of the patient when she was in the room with the physician.

We know that nursing notes are very often not written contemporaneously with the assessment of the patient. Regarding this situation, how could the 8:30 a.m. note have been entered differently so that it may have more accurately represented the factual circumstances and, perhaps, shifted liability from the nursing staff to the physician?

Nurses are challenged on a daily basis to perform double duty when providing patient care, including caring for the patient and documentation of the care provided. Interacting and providing care to the patient is time-consuming. On top of that, the nurse must document the care provided, communication with family and physicians, new orders/treatments, follow-ups and any changes in the patient’s condition. Nurses are considered superheroes for everything they do day-in and day-out for their patients. However, they face challenges in caring for the patient and documenting at the same time.

Nursing documentation should be factual, accurate, complete and timely. This is easier said than done. The following are tips for improving nursing documentation:

• Most organizations chart by exception, which may set a precedence to limit the quality and amount of documentation. Nurses are encouraged to conduct and document a head-to-toe assessment at the beginning of their shift or when taking over care of a patient. By conducting and documenting the results of the full assessment, the nurse paints the picture of what the patient looks like at that moment. From there, charting by exception can occur, including any change in condition, rounds, communication with other health care providers, wound care, ADL’s, etc.
• 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 “real time as possible”. Even the best nurse is 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. This also limits confusion about what occurred between patients and potentially documenting on the incorrect patient.
• Nurses should take extra precautions 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 risk of not documenting something important that could be ultimately detrimental to defending a medical malpractice claim increases.
• Nurses should avoid general statements that can be misconstrued by others. Nurses are encouraged to the document the care provided to the patient clearly and in detail. Charting should be clear enough for someone to come back a year later and understand the entirety of the care provided based on what was documented.
• Nurses should not rely on their memory. Nurses provide care to hundreds of thousands of patients each year. It is unrealistic to expect that nurses can remember details about every patient. That’s why timely and detailed charting is important.,
• When there is any change in the patient’s condition, documentation should include 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 the notification was made (by phone or in person during rounds), and any other key facts important to the patient’s story.

Regarding this claim, the nurse could have documented more details, including:

• Time and location when the rounds occurred
• Information provided to the physician during the rounds (specifically the details of the lower extremity assessment and/or any changes)
• Physician’s response to the information provided
• If the physician provided any follow-up orders based on the information provided.

Based on the limited documentation provided by the nurse in this case, there was an increased risk of not meeting the standards of care.

Nurses are a key part of telling the patient’s story. As vital as caring for the patient is, documentation is just as important because it can provide a safeguard for both the nurse and hospital in medical malpractice claims.