Nursing Documentation: What to Do and What to Avoid

Nurses are key players when it comes to documenting patient care. That documentation comes under scrutiny when a medical malpractice claim is filed, potentially exposing problematic practices that could make a difference in your healthcare facility’s liability.

This month, we invite you to explore three different true-to-life claim scenarios where nursing documentation was key to the case and how to improve nursing documentation practices in your healthcare facility.

Scenario 1: Patient Advocacy

The patient presented to the Emergency Department with signs and symptoms of a possible stroke. The patient and the family member present at the time of triage and initial exam were unable to provide context or history for the patient’s symptoms.

Before obtaining a CT scan, the physician discussed the patient’s status with the on-call neurologist. An order was given to the nursing staff to administer tissue plasminogen activator (TPA). The nurse receiving the order documented a dispute with the ordering physician in the patient’s chart about administering TPA expressing her concerns. The ER Director was included in the discussion regarding the concerns of administering TPA to this patient without the CT scan results.

The ED physician stood behind his care plan decision based on the neurologist’s consultation. He adamantly ordered and obtained consent from the patient’s family member to administer the TPA.

When the CT scan results were available, they revealed the patient had an aneurysm in the artery under his collar bone. TPA was immediately discontinued, and the patient was transferred to a higher-level care facility.

There is a balance between advocating for patients and creating a discourse between care team providers when considering liability exposures. Nursing staff often face criticism in a claim for a failure to advocate for their patients. Ultimately, the decisions regarding a patient’s care are the physician’s decision. However, nurses are responsible for their actions and the consequences of the implementation of care. As a result, they are expected to use their critical thinking skills in evaluating physician orders.

In this situation, the nurse was trying to advocate for the patient by voicing concerns and escalating them to leaders when the nursing and medical staff disagreed on the best course of action. A nurse's first responsibility is to patient safety. Each organization should have a policy to describe how conflict resolution in situations such as this should be handled.

If the disagreement is not resolved and a nurse makes the decision to refuse to implement a portion of the patient’s care, that nurse should be expected to communicate their decision to the treatment team expeditiously to minimize risks to the patient. This communication involves documenting facts and specific steps taken directly relating to patient care into the patient record as well as steps taken to escalate the concerns.

Care must be taken to avoid placing blame or derogatory comments in the medical record when documenting patient advocacy issues. While this type of situation can cause emotions to run high, it's important to stick with the FACT acronym when documenting in the medical record.

Scenario 2: Failure to Assess

Nurses are frequently involved in claims regarding allegations of failure to assess and notify the physician. A recent claim scenario involves a wound care nurse who assessed a patient’s foot for possible development of a new ulcer and failed to document her findings or report them to the attending physician. The patient’s foot deteriorated rapidly, resulting in an eventual amputation.

Complete nursing assessments of patients should be done at least at the beginning of each shift and additionally according to your healthcare facility’s policy. Findings from the assessment should be communicated to the physician as well as passed along at the handoff of patient care to ensure the continuity of care.

Although the wound care nurse in this situation failed to report or document any findings about the new pressure ulcer, every nurse in charge of this patient's care had the same responsibility to complete a skin assessment on the patient. All changes in the patient's condition — which include skin assessments — should be documented in the medical record and reported to the physician.

Scenario 3: Failure to Monitor

In another case, a patient suffered a fall out of her bed in the ED. The nurse documented the fall and that the patient suffered no obvious injuries. Existing orders were continued.

The following morning, the physician rounded on the patient. It was noted that the patient had increasing mental decompensation. During that exam, a family member told the physician that she had fallen out of bed the evening before. The physician had no prior knowledge of the patient’s fall during the previous shift. When the nurse was contacted about the fall, he went into the chart and made a late entry stating that he had notified the physician of the fall and no new orders were given.

It's a common misconception that adverse events should not be documented in the medical record. Events that occur should absolutely be documented in the patient's record. However, the facts of the situation should be documented, not insinuations or opinions.

For example, if you did not actually see the patient fall, you would not document that the patient fell. If you walked into the room and the patient was sitting on the floor and said they fell, that's exactly what should be documented with the words “the patient stated” in quotations. This would represent the facts of the findings.

Incomplete or lack of adverse event documentation is a red flag that can:

• Demonstrate incomplete patient care.
• Demonstrate noncompliance with organizational policies.
• Support allegations of negligence.
• Support allegations of fraud.

The response to a patient’s fall should be outlined in your fall prevention policy, and the safety of the patient should always be the top priority. A patient assessment immediately following the occurrence should be documented including actions taken to treat or care for the patient. Notification of the physician should always be included in the response and documented in the record.

If a fall is unwitnessed by staff or it is unknown if the patient hit their head during a fall, serial neurological assessments should also be implemented to ensure no mental deterioration. Neurological assessments are a nursing intervention that can be added to the care plan according to an assessed need rather than a physician's order.

When documenting an adverse event or an unanticipated outcome, you should include:

• “Known facts” about the event
• Physician notification
• Care given in response
• Effect/injury to the patient

Do not include:

• Subjective feelings or beliefs
• Speculation or blame
• References to incident report forms
• References to Risk Management

In this case, the nurse also documented a late entry regarding the adverse event. Late entries should be avoided when possible. When they are necessary, follow the organizational policy on how to appropriately document the entry into the medical record. Late entries are a red flag in documentation because they give the impression that the care team is trying to cover something up.

The Importance of Documentation in Nursing

Accurate and complete nursing documentation is key when it comes to defending claims. Good nursing documentation practices within your healthcare facility will help your patient care documentation stand up to scrutiny.

Interested in nursing documentation training? LHA Trust Funds offers on-site training developed specifically for nurses that stresses the importance of proper nursing documentation in the medical record.

About The Authors

Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.