The Importance of Proper Medical Documentation

This claim study demonstrates how poor documentation habits can both alter a nurse’s credibility and hinder a healthcare facility’s ability to successfully defend itself from a claim.

A 48-year-old male patient was admitted for a total knee replacement. His medical history included a below-the-knee amputation of the opposite leg and the patient used a prosthetic on that leg.

On the first postoperative morning, he was assisted to the bedside commode and given instructions to push his call bell when he was ready to get back in bed. The nurse stated that the patient’s wife was at the bedside when the nurse left the room. But when the patient called for the nurse, he said he needed help because he had fallen while propping up the surgically repaired leg. The nurse found the patient on the floor, later stating that the patient’s wife left the room without notifying the staff. The patient required a return trip to the operating room due to bleeding and wound separation.

The patient brought a claim for damages against the facility as a result of the incident. During the course of discovery when he and his wife were deposed, both denied that the wife was in the room when the nurse left him alone. The patient also denied he was given a call bell and stated no one assisted him back into bed after he fell.

A medical review panel was formed to review the care provided by the facility. Since the nurse and plaintiff versions of events conflicted, the panel found an issue of fact not requiring expert opinion. This means that the issue before the panel was not a question requiring a medical opinion, but rather an examination of credibility.

The plaintiffs subsequently filed suit in district court and retained a nurse expert. When the nurse expert was deposed, she acknowledged that if the facility nurse’s version of the events was true, the standard of care was not breached.

As we know, documentation plays an important role in the defense of all healthcare liability claims. This case is no different. The nurse did not document the patient’s fall in the electronic medical record at the time it happened. A handwritten note was placed in the record 18 days later and tagged as a “late entry.” The nursing expert was very critical of this practice and testified she did not believe the nurse could know such specifics that far after the event. She acknowledged that nurses don’t always document at the exact same time an event occurs. However, waiting 18 days arouses suspicion as to what motivated the nurse to document the incident at that time. The substantial length of time that had passed before the note’s late entry into the medical record caused the expert to question the facility nurse’s documented version of events.

The expert also pointed out another entry made by the same nurse in the patient’s medical record where the patient’s admit assessment was not documented until the next day, and the entry was backdated. This allowed the expert to characterize the nurse’s late documentation as habitual.

These documentation problems greatly influenced the eventual decision to settle the case and avoid trial.

Preventing Poor Documentation

This particular claim features two common risk management topics: Patient falls and poor documentation. As the above incident shows, patient falls can lead to potentially devastating injuries for the patient and a healthcare liability claim for the facility where the fall occurs. Preventing patient falls- and the potential injuries that come with them- are part of the nursing staff’s daily responsibilities. Paired with good documentation habits, nurses can lessen the impact of this type of claim.

The Agency for Healthcare Research and Quality (AHRQ) estimates up to 1 million hospital patients fall each year. Fall prevention in healthcare facility settings is the subject of many quality improvement efforts as well as years of research. Nurses can help prevent patient falls in a multitude of ways. Instructing patients and their caregivers on safety is a crucial part of this process, as is demonstrating how to use the call light system for assistance in getting up for patients at risk for falls. Documenting these instructions as well as the patient or caregiver’s response and verbalization of understanding is just as important.

If a patient is noncompliant and gets out of bed alone when instructed not to do so, nursing staff should recognize this high-risk behavior and document it in the patient’s medical record. The nurse should then re-instruct both the patient and any caregivers on appropriate facility procedures.

If an incident occurs, it is important to document all happenings, actions, and notifications. While nursing staff may not be able to document a fall in real-time, an incident report should be completed as soon as possible. Refer a copy of this report to the risk manager so the document stays secure. The incident report is not a part of the patient’s record.

A post-fall assessment should also be completed. Monitor the patient’s vital signs, evaluate any injury, implement necessary interventions and notify the physician. Document the incident in a patient’s record as soon as possible when all details are fresh and information about the event remains accurate. Be vigilant regarding dates and times on all documentation entered into the record. Late entry, as shown in the reviewed claim, represents suspicious activity and casts doubt upon the credibility of nursing staff and the facility itself.

Learn More

Want more fall prevention resources? check out our Fall Prevention toolkit.

For more information to support quality nursing care, view our Nursing Process toolkit.