3/13/2015
Too Much, Too Little or Just Enough?
MESPAN Spring 2015
The patient was fat, and this was obviously due to a
demon.
If the adult in the hospital is a child, he may miss his
parents.
The patient was passing wine frequently, because he
said his bladder irritated him.
A cross infection committee was set up in the hospital
to deal with affection between patients and nurses.
Brook R. And after that Nurse? Souvenir Press;
London, England: 1966.
Have you ever been deposed/related to a potential
lawsuit?
At the end of the day, does your clinical documentation
tell the story?
Would your documentation support you in a court of
law?
Do you remember the patient you cared for 5 years
ago in Bay 9 at 10:15 am?
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Based on nature of the nurse-patient relationship
“Legal” status created when the nurse is legally
obligated to provide nursing care to a patient
Courts look to determine if a nurse has performed as a
‘reasonably prudent’ nurse would perform
Does care fall below the ‘acceptable’ Standard of Care?
◦ Failure to ‘live up to a standard’
◦ Pt has a right to expect standard care,
◦ We have ethical, legal and moral obligation to satisfy that
expectation
Consequences of a breach:
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Malpractice with compensatory reward $$$
Loss of license to practice
Loss of job
Loss of ability to work
Any action that falls below generally accepted
standards of nursing care AND causes injury to a
patient
Requires “proximate cause” or PROOF
◦ Is there a connection between what the nurse did or didn’t do
and the subsequent injury?
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Nurse with knowledge
Nurse with skill
Nurse who cares
Nurse who is diligent
39% of medical malpractice claims occurring in the PACU
had nursing listed as the primary responsible party
The top three risk management issues among PACU nurses
included:
◦ Clinical judgment: 24% of the claims
Failure to monitor the patient and appreciate changes in vital signs
◦ Administrative issues: 19% of the claims
Failure to follow policies/procedures and the need for staff training
◦ Communication issues: 19% of the claims
Involves communication between providers, as well as poor rapport with
another health care provider
Nursing
Other
Failure to follow standards of care,
including failure to
◦ perform a complete admission
assessment or design a plan of care
◦ adhere to standardized protocols or
institutional policies and procedures
(for example, using an improper
injection site)
◦ follow an MDs verbal or written
orders
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Failure to use equipment in a responsible
manner, including failure to
◦ follow the manufacturer’s recommendations
for operating equipment
◦ check equipment for safety prior to use
◦ place equipment properly during treatment
◦ learn how equipment functions
Failure to communicate, including failure to
◦ notify a physician in a timely manner when
conditions warrant it
◦ listen to a patient’s complaints and act on them
◦ communicate effectively with a patient (for
example, inadequate or ineffective communication
of discharge instructions)
◦ seek higher medical authorization for a treatment
Failure to assess and monitor, including
failure to
◦ complete a shift assessment
◦ implement a plan of care
◦ observe a patient’s ongoing progress
◦ interpret a patient’s signs and symptoms
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Failure to act as a patient advocate, including
failure to
◦ question discharge orders when a patient’s
condition does not warrant it
◦ question incomplete or illegible orders
◦ provide a safe environment
Failure to document including failure to note in the
patient’s medical record
◦ a patient’s progress and response to treatment
◦ a patient’s injuries
◦ pertinent nursing assessment information (e.g.,
drug allergies)
◦ a physician’s medical orders
◦ info on phone conversations with physicians,
including time, content of communication between
nurse and physician, and actions taken
Most common claims occurring in the PACU include:
◦ Anesthesia related (e.g., damage to teeth)
◦ Improper anesthesia administration
◦ Improper management of the surgical patient
◦ Failure to monitor the patient’s physiologic status
◦ Delay in treatment
◦ Delay in diagnosis
◦ Wrong medications
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The illusion of negligence exists when evidence of
what really happened is unavailable…
Not charted, not done.
Accurate and comprehensive documentation
Purposes of documentation
◦ To communicate the patient's condition to other health
professionals
◦ To assess for improvements that might be needed by risk
management and quality management
◦ To obtain data for research
◦ To obtain reimbursement—from the government and
insurance
◦ As a legal record
◦ To use as data for quality-of-care review
To avoid litigation we must comply with
established standards of care.
Sources:
◦ State and federal legislation/statutes
Defines scope of practice/accountability
◦ Practice guidelines
◦ Policies and procedures
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3/13/2015
At
the end of the day, does your charting
tell the story?
“I would hate to be the nurse trying to defend what I did for
the patient prior to transfer to a higher level of care,
because the EHR looks like nothing was done.”
“Having had to do quality-of-care reviews, I can truly say
that there are instances when after reading the entire
record, I still cannot tell what went on with the patient.”
Lawyer: Would you please read your entry on March 28?
Nurse: Patient fell out of bed…
Lawyer: Thank you. Did you see the patient fall out of bed?
Nurse: No.
Lawyer: Did anyone see the patient fall out of bed?
Nurse: Not that I know of.
Lawyer: So these notes reflect only what you assumed
happened, correct?
Nurse: I guess so.
Lawyer: Is it fair to say then, that you charted something as
fact even though you didn’t know that it was?
Nurse: I suppose so.
Lawyer: Thank you.
Legibility (including identify
of ‘author’)
Prompts
Accessibility
Ability to tell the story
Length of time to chart
Copy and paste
CPOE
Less tampering
Bar coding
Standardization = $$
ADVANTAGES
Expensive startup
Downtime/crashes
Training
“Check boxes”
Length of time to chart
Copy and paste
CPOE
Privacy – screens/locations
Increased liability r/t
discoverable evidence
DISADVANTAGES
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“normal respiratory assessment”
Once a pattern of mechanical or rote charting is
established, the nurse may become careless
about documenting exceptions
Boxes left unchecked can draw the wrong
conclusion
Boxes checked can give the wrong assumption
Blanket statements need all elements of that
assessment defined in order to be used
correctly
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Chart accurately
◦ It is very difficult to prove that something
was done if it is not charted!
◦ On the other hand, deliberate inaccuracies
can totally destroy defense and expose nurse
to criminal charges of fraud
Chart objectively
◦ Describe only what you observe – what behaviors do you
actually see?
Avoid labels…
Abusive
Drunk
Drugged
Lazy
◦ Do not use words such as “seems,”“apparently,” or
“appears”
◦ Write legibly, and use standard abbreviations adopted by
the health care facility
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Advantages
Assessment defined
Eliminates redundancy
Reduced documentation
Concise documentation of
routine care
Emphasized abnormal
findings/facilitates
treatment plans
Identify trends across shifts
Disadvantages
Questions arise if elements
completed but omissions not
recorded
“Normal” must be
specified/qualify “exceptions”
Clear policies/
procedures/guidelines
understood by ALL staff
members linking CBE format to
charting
Do not use the chart to criticize or complain
◦ Use other appropriate avenues if there is
criticism of another nurse
Do not destroy or obliterate documentation
◦ Do not use correction fluid or any other kind
of eradicator
◦ Draw one line through the error, initial, and
date the line
Do not leave vacant lines; sign every entry
Chart as promptly as possible after the care is given
Correct grammar, spelling, and punctuation make a
difference
Do not chart for someone else or allow someone
else to chart for you
Use appropriate procedure for documenting a late
entry
**LAWYERS LOOK FOR WHAT YOU DIDN’T CHART!
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Document patient and/or family teaching
Document disposition of any personal
belongings
Document any nursing interventions and
patient responses to those interventions
Document any communication with a
physician or supervisor concerning a patient's
condition
All diagnostic records & reports must be properly
labeled, sequentially listed or referenced and kept
with the medical record
◦ ECG, fetal monitor, and other diagnostic recording
strips; consults, labs, xrays and other test reports;
procedure results
All unofficial papers, such as a nurse’s to-do list,
must be removed from the patient care area so they
are not included in the medical record
Abbreviations on the Joint Commission’s Official “Do
Not Use” List should not be used
◦ Other abbreviations should be approved by your
institution
◦ Avoid ambiguous abbreviations such as “SOB,”
which can mean either “shortness of breath” or
“side of bed”
Nurses must read medical record entries and assess
the patient themselves before cosigning another
clinician’s assessment records
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The pt’s response to interventions and the
clinician’s response to a worsening condition
or worrisome indicator must be recorded
promptly
Physicians’ orders must be transcribed and
accomplished as quickly as possible
D/C instructions and the pt’s response to them must
be noted
Personal, critical and judgmental opinions concerning
health care providers, patients and family members
must not be recorded
All attempts to contact other health care professionals
must be documented, including the time of the
attempt or contact
◦ What’s the best way to know the patient understands?
◦ Do not document any speculation about why
another provider might not have responded promptly
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3/13/2015
Use has changed from punitive measure to a
documentation of unusual events
◦ Should be no fear of reprisal or other negative consequences
All actual and potential injuries must be reported
Should be initiated by the person who observed the event or the
first to become aware of the incident
Incorporate patient's description into the report by use of direct
quotes
Documentation should be factual and objective
Allows risk manager to assess situation and decide on best
corrective action
Record fact about event in nurses’ notes, but not fact that incident
report filed
Document any calls made to report changes in pt condition
Important information to include
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Specific time call was made
Who made the call?
Who was called?
To whom information was given
All information given
All information received
When obtaining consents (and any other time appropriate),
have another witness listen in (total of two witnesses)
Do not ignore any warnings from the computer
Do not allow anyone to have access to your password,
even if temporarily
Know your hospital policy on late entries and error
corrections
◦ These warnings are patient safety reminders
◦ Documentation of these types of entries will most likely
require a different approach
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3/13/2015
Access information only as needed
◦ Do not access records if you are not involved in the care
◦ The consequences of unethical access could lead to criminal
and civil proceedings
Request in-services for any new implementation of
online documentation or new systems
Know and follow your institution policy on how to
handle patient printouts/secure emails
◦ Shredding or the elimination of patient identifiers should be
included in that policy
One case included a patient who was recovering from
general anesthesia. The PACU nurse recorded that the
alarms were on (as were required by policy), but the PACU
nurse failed to actually check the alarms and just assumed
the alarms were on. None of the alarms, either for the
cardiac monitor or the pulse oximeter, were on and the
patient experienced respiratory depression, and then had a
cardiopulmonary arrest, leading to anoxic brain damage.
This is an example of a human factor causing an error in the
PACU. The nurse became used to the routine of the
monitor alarms being on and failed to check them.
Reduce mental errors by reducing stress and
fatigue
Expand knowledge and develop programs to
minimize inevitable errors by simplifying steps
and systems
Avoid reliance on memory; simplify tasks and
standardize procedures
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3/13/2015
Reduce drug errors of all types by
systematizing and using dedicated staff
members for use of drug delivery systems.
Standardize equipment, such as same location
in each unit, and identify equipment that is
prone to causing errors
Training and education: use of simulators and
performance certification
Use a process-of-care approach, whereby decision
making is standardized, and development of error
reduction program
Improve the structure of the department by having
leadership direction that is multidisciplinary with
outcome measures and reporting along with use of
external benchmarks
Be responsive to change and resource allocation
Be extra careful when you think you are "too busy."
Be aware of critical times such as:
◦ Abnormal vital signs
◦ Codes
◦ Transfers and shift handoffs
◦ Verbal orders
◦ Noting physician’s orders
◦ Verifying medication orders
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3/13/2015
How long does the lab have to report critical values?
◦ Within 15 minutes of lab verification
How long does the nurse have to report critical
values to the physician?
◦ Within 30 minutes
What if the physician can’t be reached?
◦ Follow the facility’s fail safe plan or chain of
command
Avoid general statements.
Beware of general statements that can be
misconstrued. For example, you wrote “Dr. Smith
called.” Did you mean:
◦ you called and are waiting for a return phone call?
◦ the physician called the nurse?
◦ the nurse called and spoke to physician?
What is a better option?
◦ “MD paged, assessment findings discussed, and no additional
orders at this time.”
Some facilities use “charting by exception”
Document findings are “within normal limits”
(WNL) unless otherwise noted
◦ How do you define “normal limits”?
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No charting should be done in advance.
Charting patterns including flow sheets will
be reviewed.
◦ “Too perfect” charting may raise doubts.
◦ Patient assessment such as fall risk or skin
assessments must be carefully performed
and documented. Failing to do so is a
common error.
Sign each entry correctly, including date and time.
◦ Illegible signatures may lead to all nurses on duty being
named in order to “cast a wide net.”
◦ Date and time are crucial when creating a chronology of
events.
Evaluate any new onset of pain.
◦ One patient suddenly complained of a new onset of
debilitating headache after he fell and hit his head in the
hospital. This is documented as a “migraine” although there is
no previous history of migraines. 12 hours later, a CT scan
revealed brain stem herniation.
Hospital bills will be
audited for items
such as tubing
charges, etc. to
determine if policy
and procedure was
followed to prevent
infections
May also be audited
for accuracy
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The statute of limitation is typically 2 years.
Medical malpractice cases may be filed up to the end
of these 2 years. It may take several more years before
a potential case goes to trial. Hence, a nurse may still
be testifying long after the events.
To avoid all these troubles, it is important that you pay
attention to nursing documentation. It may not just
save your patients' lives—it might save your career,
too.
To maintain confidentiality in a busy Phase I PACU
with two patients next to each other, the nurse
should:
a. Move one patient to the end of the room
when discussing specific information
b. Ask the patient not being spoken to not to
listen to the conversation
c. Pull the curtain around the patient being
spoken to and lower your voice
d. Write everything down and do not speak
aloud
Criteria used to measure the clinical performance of
the nurse may include showing that the nursing care
provided aligned with accepted community practice
and demonstrating:
a. That a nurse is accountable only to the unit
manager
b. Compliance with ASPAN’s Standards of
Perianesthesia Nursing Practice
c. Lack of proximate cause during wound
assessment
d. That the nurse’s skills equal the performance of
a certified colleague
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Standards of care (whether established by state or federal
law, nursing and specialty organization, or accrediting
agencies) are legal measures to determine the acceptability
of a nurse’s professional actions. Whether certified or not,
nurses must meet the same standard of acceptable care.
Expert witnesses may attest to whether the nurse acted
responsibly to provide nursing care as another “ordinary,
prudent nurse would have performed in the same or
similar manner” and in a similar circumstance. The plaintiff
who brings the lawsuit, not the nurse-defendant, must
prove both proximate cause and damage.
When documenting patient assessments, it is
important to:
a. Leave several blank lines so that you can be
sure to have enough space to finish your
narrative charting
b. Date and time each entry and sign your name
at the end of the documentation
c. Include every single comment made by the
patient
d. Document an assessment every 10 minutes,
even if nothing has changed
Several PACU nurses are eating together in the
cafeteria. They begin talking about several of the
young teenage girls they took care of that morning
and unintentionally interchange names and
diagnoses. One of the nurses incorrectly identifies
the wrong girl as having been pregnant. This
discussion involves a quasi-intentional tort called:
a. Invasion of privacy
b. Defamation of character
c. Disclosure of confidential information
d. Misrepresentation and fraud.
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Quasi-intentional torts are torts in which the intent of the
actor may not be as clear as with the intentional torts, but a
voluntary act on the defendant’s part occurs. Common
quasi-intentional torts seen in health care are defamation,
breach of confidentiality, invasion of privacy, and malicious
prosecution.
Defamation includes the “twin torts” of libel (written word)
and slander (spoken word). It involves wrongful injury to an
individual’s reputation (i.e., his or her good name, respect,
or esteem) through either oral or written communication to
persons other than the person defamed. Nurses are advised
to avoid any type of subjective language when charting and
to avoid derogatory comments about patients or their family
members. Defamation is a communication that “tends to
hold the plaintiff up to hatred, contempt, or ridicule, or to
cause him or her to be shunned or avoided”.
The nurses continue discussing these young patients
they have been caring for, commenting on
information the girls relayed to them during the
admission process. Discussing this information in the
cafeteria involves a quasi-intentional tort called:
a. Breach of confidentiality
b. Disclosure of confidential information
c. Defamation of character
d. Libel
Breach of confidentiality is another quasi-intentional tort. The
law of breach of confidentiality protects sharing of information
by a patient with a health care provider without fear that the
information will be released to individuals not involved in the
patient’s care. In today’s electronic and information age, the tort
of breach of confidentiality, similar to the tort of invasion of
privacy, takes on new legal concerns in health care.
Information about the patient is confidential and may not be
disclosed without authorization . The patient’s right to privacy
and confidentiality is a key concept in the American Nurses
Association Code for Nurses, the Canadian Nurses Association
Code of Ethics for Nursing, and the nurse practice acts for each
state. Nurses need to be familiar with what information their
agency considers confidential and in what manner and by whom
it may be revealed.
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When documenting electronically, the nurse must be
diligent to perform what function to protect his or
her documentation?
a. Use the “save” button on the keyboard
b. Print the record for transfer of care to the next
provider
c. Sign in and out with user name and password
d. Electronically sign name after completing
documentation
Strategies for the protection of confidential health care
information must be in place when implementing a
computerized documentation and information system.
Passwords need to be of sufficient complexity with
regular changes to ensure confidentiality. Policies must
be in place requiring signing in and out of the patient
record, and sufficient penalties must be in place for
breaches of the security system.
Odom-Forren, Jan (2012-05-14). Drain's PeriAnesthesia
Nursing: A Critical Care Approach. Elsevier Health Sciences.
Kindle Edition.
Schick L, Windle P. PeriAnesthesia Nursing Core Curriculum:
Preprocedure, Phase I and Phase II PACU Nursing. Elsevier
Health Sciences. Kindle Edition.
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