To meet the expectations of the public, nurses must fully understand the duties associated with their position as set forth by not only governing bodies, but also the institutional policies and procedures affecting their practice.1 One particular duty that deserves significant emphasis is the requirement of complete and accurate documentation related to patient care, which includes what's done to and for the patient and how particular decisions about care are made.2,3
Understand nursing practice acts
The healthcare industry and the practice of nursing are heavily regulated by both federal and state laws. However, for purposes of documentation, state laws delineate certain guidelines that should be followed in the particular state of practice. State laws that are specific to nursing practice are typically called nursing practice acts and associated rules and regulations.2 The objective of any state's nursing practice act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the healthcare team. State law mandates a broad objective such as this and leaves the details to healthcare institutions, specialty organizations, and practice groups. For example, an ED nurse is guided first by state law, then institutional policy and procedure, and then specialty organizations such as the Emergency Nurses Association. The first rule of documentation for any nurse is to know the governing laws in the state of practice, the policies and procedures of the institution of practice, and the guidelines from applicable specialty organizations. It's important to note that when State law and institutional policy are in conflict, state law trumps the institution. Specialty guidelines for practice aren't legally binding, but they do create a standard of care for a patient in a particular setting. This standard of care can be used to establish what the nurse's duty should've been in a situation for which litigation occurs. The gold standard that's used for determining what a nurse's action should've been is: “What would a reasonable and prudent nurse have done in the same or similar situation?”
Boards of nursing are state regulatory agencies with a mission to “protect and promote the welfare of the people by ensuring that each person holding a license as a nurse in the state is competent to practice safely.”2 Within board of nursing regulations, nurses can find information about licensure, practice, and disciplinary processes and seek clarification of gray areas through position statements. Nurses are required to adhere to the nursing practice acts and board of nursing rules that hold the force of the law, as well as practice to the level of their knowledge and skill and intervene/advocate on behalf of patients at all times as set forth by the standards of professional nursing.2 Part of this duty to the patient is to provide for complete and accurate reporting and documentation.2
In a sometimes chaotic environment where nurses are pulled in many different directions to dispense compassion and skill and where policies and guidelines aren't altogether prescriptive about what's to be documented, nurses often raise the question of what must be documented. (See What must be documented....)
Keep your audience in mind
Many cases brought to litigation in the malpractice arena hinge on poor communication between healthcare providers of the same and different disciplines. Handoffs to subsequent caretakers for continuation of care are of particular concern. Because of the variation in interpreting some of the requirements, it may be helpful to back up and see how documentation fits into the overall picture. The first thing a nurse should be aware of is who will be reading the document and why, including:
- the healthcare team. Other members of the healthcare team will be reading the document, so it's important to provide information about the patient that's accurate and complete, reflecting a picture of the patient while under the watch of each nurse. The overall goal of nursing documentation is to create an illustrated timeline for the care of the patient. This means that each entry by each member of the healthcare team must be integrated. Documentation uses words to paint a picture of the patient at specific time intervals and assists subsequent and interdisciplinary caretakers in determining if and to what extent changes have occurred in the patient's status. Therefore, documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care.
- the scribe. The nurse is also documenting for her own purposes. Documentation that's complete and accurate can also serve as a memory refresher when details are unclear or forgotten. Accurate and complete documentation is also important for any potential subsequent litigation. Lawsuits can typically be brought within 2 years of the date of the event resulting in a claim.4 This timeframe, also called the statute of limitations (SOL), is extended when the patient is a minor. The SOL for a minor to file a lawsuit is typically 2 years after the age of majority.4 (Note that the SOL will depend on the laws for the particular state of practice.) So, if the incident occurred in a labor and delivery setting to a newborn child, the SOL is approximately 20 years. Add to this the time from the point of filing the lawsuit up to the point where the nurse is asked to recount the events while under their watch. It may be an additional 2 years by the time the formalities of litigation take place. That's why complete documentation at the time of patient care is the only accurate way for the nurse to remember the details of the particular patient at the time surrounding the event.
- lawyers and experts. The nurse's documentation is read by lawyers and experts when a lawsuit ensues. Every microscopic detail of the medical record is examined by the lawyers and the expert nurses that they employ to make a case for their side. They're looking to see what went wrong and what could have been done better. The goal is to provide complete and accurate documentation about patient care that was rendered according to acceptable standards of nursing care.
- the judge and jury. The nurse's documentation may also be read by nonnursing or nonmedical jurors deciding a case. These cases are already seen as complex and confusing to someone that isn't familiar with the healthcare world. This is another reason why it's important to be succinct and clear with all entries.
Follow the nursing process
In addition to familiarity with the professional standards and facility policies as they relate to treating certain presentations, another cardinal rule of documentation is to follow the nursing process completely. The nursing process requires assessment, diagnosis (nursing), planning, implementation, and evaluation.2 This process must be reflected in the documentation of interactions with the patient during care. Many facilities have streamlined this critical thinking process with acronyms such as PIE (Problem-Intervention-Evaluation), which provide a simplified process to remind the nurse what needs to be documented in accordance with board of nursing directives.
The following pointers may help to guide the nurse in documenting completely and accurately while avoiding some common mistakes.
- Never document an acute abnormality found during assessment without documenting the intervention initiated. Example: If a detailed assessment reveals chest pain, then the intervention (such as implementing an order for nitroglycerin administration) and evaluation should follow.
- Never document the intervention initiated without documenting the evaluation/response of the patient. Example: For a patient with chest pain, the intervention that's documented should be followed by an evaluation as to the efficacy of the intervention. Was the nitroglycerin successful at relieving the chest pain?
- Never document a body system abnormality without elaboration. Example: If a patient presents post-motor vehicle accident with a neurologic deficit in the lower extremities (possible spinal cord injury), it's vital to note the details. Over a period of time, the deficit may worsen and with each assessment, the severity should be noted (such as numbness versus inability to move). In this example, the undetected exacerbation of the deficit could result in permanent damage.
- Always document the patient's baseline mental status (if known). Example: A patient who presents with altered mental status who's normally altered should be evaluated for the specifics of his condition. The fact that he thinks the year is 1960 may be normal for him, but it may be significant if he's normally oriented to time. Simply attributing any abnormalities found in mental status to the fact that the patient is normally altered may lead to missed indicators of an acute illness or injury.
- Don't confuse visual, audible, and tactile assessment. Example: Although it sounds simple, it's vital that the nurse documents exactly the sensory method used in assessment. If the patient has a normal breathing pattern as evidenced by sight, then the nurse shouldn't document that bilateral breath sounds were clear to auscultation unless a stethoscope was used to reveal evidence by hearing.
- Reconcile mismatched objective and subjective assessment findings. Example: Pain is a subjective assessment when stated by the patient. If a patient reports a 10 on a pain scale of 1 to 10, this reflects that he's in severe pain. But, if he's sitting up in bed playing cards with a family member at the bedside, this picture is drastically different than if he were diaphoretic and writhing in pain. In both scenarios, the patient may report pain as a 10 out of 10. To track changes in the objective data, the nurse should reconcile via documentation when subjective and objective data don't match.
- Don't become complacent with check-off assessments. Every facility has some sort of check box system for documenting the patient assessment. It's vital that documentation be reflected as accurately as possible. Example: There's no single way to undermine credibility in court more powerful than documenting that a patient with a right below-the-knee amputation has bilateral pedal pulses that are strong and equal. All other parts of the assessment will have doubt shed on them related to the nurse's error in accurate documentation of this issue.
In addition, general guidelines to follow include:
- Always assess the patient at the time of discharge or transfer. It's vital to know the status of a patient before he leaves or enters your care.
- Always use a chronologic documentation format, providing separate entries for each narrative item. Block charting, or charting that doesn't separate each activity by timed entry, doesn't provide a clear picture of the sequence of events surrounding the care of the patient.
- Never use medical terminology unless the meaning of the word is known.
- When in doubt, spell it out. Be familiar with your institution's policies and procedures related to acceptable abbreviations.
- Use quantifiable data with descriptions. Reference to common objects, such as a quarter or soda can, to describe the size or shape of wounds may be useful with awkward shapes or when there isn't access to a measurement device.
- Always write legibly. There's no single factor regarding documentation that bears more importance than the ability of the audience to read what's written.
- Ensure that late entries should follow your facility's policy.
Complete and accurate is the key
Nurses must know state law and the policies and professional standards related to the specialty in which they practice. When in doubt, a mentor, supervisor, or expert should be consulted to clarify any points of confusion. Most importantly, nurses should document based on evidence-based practice and the standards of care of a reasonable and prudent nurse.
2. National Council of State Boards of Nursing. Model Nursing Act and Rules.https://www.ncsbn.org/312.htm
4. Texas Civil Practice & Remedies Code. (1985, September 1). Title 2, Chapter 16, Section 16.003.http://tlo2.tlc.state.tx.us/statutes/cp.toc.htm
What must be documented in order to legally satisfy the accurate and complete requirement for documentation?
Using one state's example, the specific items required by the Texas Administrative Code Title 22 Part II Section 217.11(1)(D) include:
- status of the patient (assessments)
- nursing care rendered to the patient (what was done to or for the patient) physician/dentist/healthcare provider orders
- medications and treatments and the response/evaluation of the patient when an intervention has been made.1
Subsection (v) of this same section also requires that “contacts with other healthcare team members concerning significant events” be documented.1
These guidelines are typical state requirements for documentation.2 Although the requirements appear to be straightforward, variations in their interpretation sometime cause nurses difficulty with accurate and complete documentation. For example, what does “significant event” mean in subsection (v) as quoted above? This particular subsection emphasizes communication among members of the healthcare team.
The answer is that anything that will create a more defined picture of the patient should be documented.
2. National Council of State Boards of Nursing. Model Nursing Act and Rules.https://www.ncsbn.org/312.htm