Managing

Documentation
Risk

A Guide for
Nurse
Managers
Patricia A. Duclos-Miller
MS, RN, CNA, BC
SECOND EDITION
Managing
Documentation
Risk

A Guide for
Nurse
Managers
Patricia A. Duclos-Miller
MS, RN, CNA, BC
SECOND EDI TI ON
Managing Documentation Risk: A Guide for Nurse Managers, Second Edition is published by HCPro, Inc.
Copyright ©2007, 2004 HCPro, Inc.
All rights reserved. Printed in the United States of America. 5 4 3 2 1
First edition published 2004. Second edition 2007.
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Managing Documentation Risk, Second Edition
Dedication
To my family, who have always supported my endeavors.
Acknowledgement
A sincere thank you to my editor who made this book a pleasure to revise. Her editorial skills
added tremendously to the value of the book.

oedication
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CON1lN1S
About the author ..........................................................................................................................................................................................viii
Introduction ........................................................................................................................................................................................................ ix
Key aspects of documentation ................................................................................................................................................... 1
What every nurse manager needs to know ................................................................................................................................... 1
Nurse manager responsibilities ................................................................................................................................................................ 2
Let the nursing process be your guide ............................................................................................................................................... 3
Nursing diagnosis and Nursing Outcome Classification ...................................................................................................... 7
Outcomes identification ............................................................................................................................................................................... 8
Planning ....................................................................................................................................................................................................................11
Implementation .................................................................................................................................................................................................12
Evaluation ................................................................................................................................................................................................................12
Organizational policies, protocols, and practices ....................................................................................................................15
Case Study: Good documentation reflects the nursing process ................................................................................16
Reducing risk and culpability through defensive documentation .............................................21
Your documentation: Truth or consequences? ........................................................................................................................21
The truth ..................................................................................................................................................................................................................21
Case Study: The truth comes out .......................................................................................................................................................23
Risk-management guidelines for documenting care ............................................................................................................23
The consequences ............................................................................................................................................................................................24
Case Study: Neglected documentation .........................................................................................................................................25
Case Study: Incomplete documentation ......................................................................................................................................26
Case Study: Improperly altered documentation ....................................................................................................................28
Case Study: Neglected documentation II .....................................................................................................................................29
Handling documentation errors ...........................................................................................................................................................30
Adverse events: When bad things happen to good nurses .............................................................................................31
Documentation of adverse events ......................................................................................................................................................33
Incident reports ..................................................................................................................................................................................................35
Tips for writing an incident report .....................................................................................................................................................36
Risk-reduction recommendations for nurse managers ......................................................................................................37
Contemporary nursing practice: Are you and your staff there? ....................................................41
Are you using contemporary nursing practice? ........................................................................................................................41
Certification ...........................................................................................................................................................................................................42
Professional standards ...................................................................................................................................................................................43
Code of ethics ......................................................................................................................................................................................................47
State Nurse Practice Act ..............................................................................................................................................................................48
Threats to licensure .........................................................................................................................................................................................50
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Federal and state regulations ...................................................................................................................................................................51
The Joint Commission ...................................................................................................................................................................................54
Organizational policies and procedures..........................................................................................................................................54
Resources .................................................................................................................................................................................................................56
Functions of the medical record .............................................................................................................................................59
The effects of staff documentation on compliance, quality, and reimbursement........................................59
Medical record as communication .....................................................................................................................................................59
Medical record as a demonstration of compliance ...............................................................................................................61
The Joint Commission and “tracer methodology” .................................................................................................................64
Quality and risk-management review ..............................................................................................................................................68
Medical record as a path to reimbursement ..............................................................................................................................69
Resources .................................................................................................................................................................................................................75
Nursing negligence: Understanding your risks and culpability ....................................................77
Legal issues ..............................................................................................................................................................................................................77
Essential definitions .........................................................................................................................................................................................77
Factors that contribute to malpractice cases against nurses .........................................................................................79
Legal risks for nurse managers ................................................................................................................................................................81
Case Study: Incompetent care ..............................................................................................................................................................85
Legal risks for nurses .......................................................................................................................................................................................86
Case Study: Chart review reveals fraudulent countersignature .................................................................................87
Professional-negligence claims against nurses ...........................................................................................................................87
Case Study: Failure to follow protocol............................................................................................................................................88
Case Study: Breach in nursing standard of practice.............................................................................................................89
Case Study: Failure to properly orient, educate, and evaluate ....................................................................................90
National Practitioner Data Bank ...........................................................................................................................................................90
Liability in special practice settings.....................................................................................................................................................92
Depositions: Preparing for the worst ...............................................................................................................................95
When it happens to you ..............................................................................................................................................................................95
Essential definitions .........................................................................................................................................................................................95
Meeting with your organization’s attorney/risk manager ................................................................................................96
Reviewing medical records and all associated policies ........................................................................................................97
The importance of a deposition ............................................................................................................................................................99
The players .......................................................................................................................................................................................................... 100
Prepare, prepare, prepare ........................................................................................................................................................................ 102
At the deposition ........................................................................................................................................................................................... 103
Tips for presenting an effective deposition testimony..................................................................................................... 104
Improving staff documentation ........................................................................................................................................... 111
Recognizing and correcting charting mistakes that increase your liability risks ......................................... 111
Eight common charting errors ............................................................................................................................................................ 112
Case Study: Failure to record medication given .................................................................................................................. 113
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Managing Documentation Risk, Second Edition
Other common charting flaws ............................................................................................................................................................ 117
The consequences of an incomplete medical record ........................................................................................................ 118
Tips to improve your staff’s documentation ........................................................................................................................... 119
Developing a foolproof documentation system................................................................................................ 125
Building on the foundation of compliance standards ...................................................................................................... 125
Evaluating your current documentation system .................................................................................................................. 125
Systems of documentation .................................................................................................................................................................... 127
Using The Joint Commission standards as the foundation of your system .................................................... 137
10 steps for building a foolproof documentation system ............................................................................................. 142
Auditing your documentation system ........................................................................................................................ 147
The important role audits play in protecting you and your organization ....................................................... 147
Building your audit system around performance-improvement goals ............................................................... 147
Measuring compliance and improvement through an audit ..................................................................................... 149
Getting your staff to use the audit tool ....................................................................................................................................... 150
Advantages of audits for the nurse manager ........................................................................................................................... 151
Nurse manager tips for auditing ........................................................................................................................................................ 151
Electronic health records ............................................................................................................................................................. 153
Nurse managers’ roles in building a computerized system that reduces liability....................................... 153
Why we need electronic health records ...................................................................................................................................... 154
Start at the beginning ................................................................................................................................................................................. 154
Benefits of electronic documentation ........................................................................................................................................... 155
The nurse manager’s role ......................................................................................................................................................................... 156
Challenges associated with the change ........................................................................................................................................ 157
Computer etiquette ..................................................................................................................................................................................... 159
Strategies for success ................................................................................................................................................................................... 161
Motivating your nurses to document completely and accurately ........................................... 165
Why nurses document poorly ............................................................................................................................................................. 165
Change: Embrace it or resist it ............................................................................................................................................................. 167
The role of education and expectations ...................................................................................................................................... 169
The good, the bad, and the ugly approach ............................................................................................................................... 170
Monitoring the work environment ................................................................................................................................................. 171
Staff-motivation tips for nurse managers ................................................................................................................................... 173
Sample audit tools ................................................................................................................................................................................ 175
Nursing education instructional guide ...................................................................................................................... 179
Continuing education exam .................................................................................................................................................................. 183
Continuing education evaluation ..................................................................................................................................................... 192
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Contents
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Figure 1.1 Respiratory Status: Airway patency (0410) .....................................................................................10
Figure 1.2 Nursing process flowchart ........................................................................................................................14
Figure 2.1 Quiz: Do I need to report this? ..............................................................................................................32
Figure 3.1 Contemporary nursing practice self-assessment .........................................................................42
Figure 3.2 ANA Standards of Nursing Practice....................................................................................................45
Figure 3.3 ANA Standards of Practice for Nurse Administrators .............................................................46
Figure 4.1 The Joint Commission hospital measure set .................................................................................66
Figure 4.2 Compliance chart review table ..............................................................................................................68
Figure 4.3 CMS Quality Measures ...............................................................................................................................72
Figure 5.1 Nurse manager risk-management checklist for adverse events ..........................................84
Figure 5.2 National Practitioner Data Bank (NPDB) Summary Report .................................................91
Figure 5.3 HIPDB reports on organizations ...........................................................................................................92
Figure 7.1 Illegible-clinical-documentation policy .......................................................................................... 116
Figure 7.2 Illegible-documentation reporting form ....................................................................................... 117
Figure 8.1 POMR example ............................................................................................................................................ 128
Figure 8.2 Example of nursing progress notes using PIE ............................................................................. 129
Figure 8.3 Example of focus charting ..................................................................................................................... 130
Figure 8.4 Example of CBE assessment standards ........................................................................................... 131
Figure 8.5 Example of outcome criteria................................................................................................................ 134
Figure 8.6 Audit tool to evaluate nursing process .......................................................................................... 136
Figure 8.7 Comparison of charting systems ....................................................................................................... 137
Figure 8.8 Nursing department—Medical record audit (based on The Joint Commission standards) ........ 138
Figure 9.1 Steps in the quality improvement process .................................................................................. 148
Figure 11.1 Transforming a gripe into a goal in five minutes ..................................................................... 172
Appendix I Sample post-fall audit .............................................................................................................................. 175
Appendix II Sample ED documentation audit tool ........................................................................................... 176
Appendix III Sample pain assessment audit tool .................................................................................................. 177
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Managing Documentation Risk, Second Edition
Patricia A. Duclos-Miller, MS, RN, CNA, BC
Patricia A. Duclos-Miller, MS, RN, CNA, BC is cur-
rently a full-time associate professor in nursing at Capital
Community College in Hartford, CT. In addition to
this position, she is a senior consultant for the Kelsco
Consulting Group in Cheshire, CT, a special lecturer for
the University of Connecticut’s management in nursing
graduate program, and a per diem supervisor at Bristol
Hospital, CT.
Duclos-Miller is a registered nurse, board certified by the American Nurses
Credentialing Center (ANCC) in nursing administration. During her 33 years in
nursing, she has been a director for quality improvement, director of nursing in
acute, home health, and long-term care settings, and a staff nurse in the special-
ties of medical-surgical, mother-baby, and neonatal intensive care nursing. She is
a recognized speaker on contemporary nursing topics, including quality improve-
ment, team building, and documentation issues.
Duclos-Miller has served in key leadership positions for professional nursing
organizations and is a contributor to the newsletter Strategies for Nurse Managers,
published by HCPro, Inc. She is the author of Stressed Out About Your First Year
of Nursing, the first and second editions of Managing Documentation Risk: A Guide
for Nurse Managers, and the first and second editions of the handbook Nursing
Documentation: Reduce Your Risk of Liability, all published by HCPro, Inc.
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Managing Documentation Risk, Second Edition
IN1kOoUC1ION
Healthcare professionals acknowledge that documentation is an essential com-
ponent of good patient care. This assumption dates back to the time of Florence
Nightingale, who viewed documentation as a vital part of professional practice.
However, when “push comes to shove” during a busy day, documentation often
becomes the least-valued aspect of care.
Every professional must reexamine his or her commitment to safe patient care and
place documentation at the top of the priority list. When patient care is reviewed,
a complete and accurate clinical record must reflect that quality care was, in
fact, delivered. This record is reviewed by payers, external and internal quality-
improvement monitors, regulatory and accrediting agencies, and, in matters of
alleged negligence, patients themselves and their attorneys. In today’s fast-paced
world with its shrinking nursing staff, a documentation system needs to be effi-
cient, timely, and complete.
Documentation can be a friend if the medical record clearly outlines the details of
care, but it becomes a foe if there are gaps. When reviewed, the medical record
must demonstrate that the patient received the best, most appropriate care pos-
sible. If the medical record does not reflect what happened, the door is open for a
claim of poor quality or questions about whether the appropriate care was admin-
istered. This possibility leads us to the old adage, “If it wasn’t documented, it
didn’t happen.” As much as we might cringe at the saying, whatever is written in
the medical record—not what you claim—will be considered the truth.
Documentation is especially important for directors, nurse managers, and nursing
supervisors, because nursing management staff bear the burden of endorsing the
facility’s policies and protocols and ensuring that the care rendered is up-to-date,
timely, complete, and meets the standards of practice. You must protect yourself,
your staff, and your organization against claims of poor quality care. It is critical
that you recognize that documentation is an important part of everyday work for
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Managing Documentation Risk, Second Edition
physicians, nurses, and other healthcare providers. If you do not see the value of
what is needed in the medical record, your efforts to improve documentation will
be not be successful.
As part of nursing management, your endorsement needs to be visible, in the
form of ongoing collaborative case reviews, continuing education concerning docu-
mentation, and development and design of a user-friendly documentation system.
Once the documentation system and tools are in place, you will have to design
an ongoing audit system to evaluate and measure compliance. To protect yourself
and your staff from liability, you must also be knowledgeable in the legal aspects
of nursing.
This book is a critical tool for anyone in nursing management who would like
to improve the quality of patient care, decrease their culpability in any potential
legal cases, and assist in decreasing the likelihood that their subordinates will be
cited in a medical or nursing malpractice case. The following chapters will provide
you with an understanding of why documentation is crucial, how to improve doc-
umentation, what makes a case vulnerable to legal recourse, and how to motivate
your staff to a level of excellence that is reflected in the medical record.
Remember, the medical record is a reflection of the care administered. It is read
by all those with rights to view it, and it will always stand on its own merits. You
and your staff need the nursing documentation to speak for itself.
Introduction
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Key aspects of
documentation
What every nurse manager needs to know
As a member of a nursing management team, you must
assume responsibility for ensuring complete and accurate
documentation. In today’s culture of accountability, your
title and scope of responsibilities will bring under scrutiny
your commitment to safe and quality patient care, so you
need to accept the responsibility whether it is part of your
job description or not. You must recognize the importance
of good clinical documentation. It is also vital that you
assist staff in practicing defensive documentation and
in avoiding the potential for legal consequences if a case is reviewed for alleged
medical malpractice.
The medical record must be accurate and complete because the information it
contains is critical for a number of people and functions. It is used to communi-
cate patients’ programs to other staff and the various clinical and ancillary depart-
ments involved in their care. It is used by the system’s quality and risk-manage-
ment department and the utilization-management committee. In some cases, the
accuracy and completeness of the clinical record is essential to healthcare
researchers. It is also referred to when professional care rendered was considered
negligent. In addition, its content is regulated by the state in which you practice,
audited by insurers (both private and public), and reviewed for compliance with
accreditation standards.
Documenting completely and accurately is considered a professional standard of
nursing practice. For every step in the nursing process, the care delivered must
be documented. The nurse manager must assist nurses in fulfilling the necessary
requirements of good clinical care and documentation. Doing so not only validates
the universally recognized professional approach to patient care, it supplies other
care providers with consistent, clear communication and validates critical deci-
sion-making that is often necessary for quality patient care.
Learning objectives
After reading this chapter,
the participant will be able to:
Discuss how the nursing
process is used in nursing
documentation
Describe how to use Nursing
Outcomes Classification
(NOC) in nursing documen-
tation


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There are many research studies that have attempted to identify why nurses
do not value the importance of their documentation. One study by Moody and
Snyder claims an estimated 15-20% of the nursing work time is spent in documen-
tation. In addition, documentation has changed over the last few decades in both
its appearance and the advent of new technology. What is still missing with these
changes is the failure to demonstrate patient continuity of care and the evaluation
of patient outcomes (Irving 2006).
The quality of the care provided to patients can only be measured by the quality
of the nursing documentation. The major reasons for documenting nursing care
include:
Documentation of the plan of nursing care
Evaluation of the effectiveness of the nursing care provided
Facilitation of communication between the patient/family and other providers
Failure to completely document can have legal consequences. If documentation
is incomplete, contains gaps, or is not consistently completed according to the
organization’s policies, it can be used to support an allegation that negligent care
was provided.
Incomplete documentation allows for juries to conclude that the nurse did not:
Collect sufficient data and plan appropriate care
Implement appropriate interventions, according to professional
and institutional standards
Make good clinical decisions
Communicate effectively

Nurse manager responsibilities
As a nurse manager, it is your responsibility to assist staff in adhering to both
clinical and documentation standards. It is also your responsibility to provide
continuing education, professional feedback, and input into policy and documen-
tation-system changes whenever possible. It is to your advantage to fulfill these
responsibilities because if your staff is involved in a medical malpractice case,
your ability to manage and meet quality and risk-management standards will be
called into question.







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Managing Documentation Risk, Second Edition
As a member of the nursing-management team, you must not only demonstrate
a commitment to providing safe and efficient patient care, but also ensure that
every clinical record reflects that commitment. That is, although you must ensure
that nursing staff comply with up-to-date standards, it is equally important to
ensure that they document that compliance accurately and completely.
Your role is to support an efficient and effective documentation system and to cre-
ate an expectation that the system be followed.
Nursing management can demonstrate support for such a system by:
Developing an efficient system that meets the requirements of regulatory
standards.
Involving the end users in the development of the system.
Emphasizing the importance of documentation through written guidelines,
policies, job descriptions, and performance appraisals. The language should
include stipulations for daily supervisory oversight, audits of the system,
and feedback to the staff.

Let the nursing process be your guide
The nursing process, as outlined by the American Nurses Association (ANA)
Nursing Scope and Standards of Practice, provides us with an established, scien-
tific approach to providing nursing care. Not only does each step guide us in our
approach, it tells us how to validate what we saw, heard, felt, smelled, said, and
did while providing that care. The process accounts for all significant data and
actions taken by a registered nurse, the documentation of which is used for criti-
cal decision-making. Therefore, your documentation of patient care should follow
the framework of the nursing process.

Assessment
The first step of the nursing process is assessment. In this step, the nurse col-
lects information about the patient’s condition, which could include the patient’s
history, the physical exam, laboratory data, and so on. So as not to become over-
whelmed, the nurse must decide which information is most useful to the care of
the patient. For example, a nurse could limit the assessment data to the admission
signs and symptoms, the chief complaint, or medical diagnosis. This first step in



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the nursing process—assessment—should always be evident in the medical record
as it provides a complete clinical picture of the patient.
An assessment should include both subjective and objective data. When docu-
menting this data, beware of inappropriate documentation practices and focus on
risk management.
Subjective data
In this context, subjective data are data that can be observed, but not measured.
Statements made by the patient or family/significant other are examples of sub-
jective data. Although every conversation may not be relevant to the interaction,
there will be times when a patient’s words need to be recorded to establish a clear
picture of how the patient perceives his or her status.
For instance, if the patient says something that can be used to demonstrate men-
tal, behavioral, or cognitive status at the time of the assessment, documentation
of the conversation can be used to measure progress or decline over the course of
treatment. If patients are unable to speak or are cognitively impaired, nonverbal
cues are essential in determining whether there has been any change in status.
These conversations with the patient/family will need to be captured in the clini-
cal record in order to provide other clinicians with an accurate depiction of the
patient’s current status.
Objective data
Nurses establish patients clinical status based on objective data, which are observ-
able and measurable. Physical exam of patients, which include key assessment
techniques such as inspection, palpation, percussion, and auscultation, provide
objective data about patients’ health status. In simpler terms, nurses’ objective
assessment is based on what is seen, heard, felt and smelt. Healthcare providers
find this much easier to validate and include in their documentation than subjec-
tive data. Objective data also includes the results of diagnostic tests.
When recording this data, however, there are risks your staff should consider. If the
objective data is not reviewed in a timely manner, a reviewer of the clinical record
may point out that you failed to interpret the data and address significant changes
of condition. There also may be situations in which critical objective data were
present but there was no subsequent documentation of an appropriate intervention.
s key aspects ot documentation
Managing Documentation Risk, Second Edition
1. The entry:
Neuro signs WNL
The problem:
Which aspects of the neurological assessment are within normal limits (WNL)? Does
“WNL” refer to cognitive, visual, musculoskeletal, cranial nerve, Coma Scale, or
something else? Lack of documentation of a complete neurological assessment can
lead to an accusation of failure to document assessments according to contemporary
nursing standards.
The solution:
Develop a neurological assessment tool that is based on current standards and ensure
that staff complete the tool according to the policy and documentation guidelines.
In addition, if the absence of critical objective data resulted in a gap in the clinical
picture of the patient, it may contribute to a lack of appropriate intervention identi-
fication. All of these situations can lead to quality and risk-management issues.
Unacceptable assessment documentation
When documenting subjective or objective data, be careful to do so thoroughly
and appropriately. The following examples of entries into the medical record illus-
trate several common mistakes:
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3. The entry:
[Incomplete I&O sheet]
The problem:
Incomplete intake and outtake (I&O) sheets. Incomplete I&O sheets can lead to allega-
tions of improper assessment and insufficient data gathering. It could then be argued
that these omissions led to a lack of decision-making, which resulted in the patient
being harmed.
The solution:
Ensure that all I&O sheets are completed in their entirety. Check for accurate dates,
times, and quantities measured for both intake and output.
2. The entry:
Grand mal seizure
The problem:
This is not a complete assessment. It is the nurse’s responsibility to give a complete
clinical description of the incident so that any reader can visualize what happened.
The solution:
Ensure that your documentation of this episode has a beginning, middle, and end.
Start by documenting the patient’s status prior to the incident, if known. Describe
any report of an aura, color, posturing, or physical change during the seizure. Record
the length of time of the seizure and the condition of the patient immediately follow-
ing it, including both subjective data (what did the patient tell you about the inci-
dent?) and objective data (what were his or her vital and neurological signs?) assessed
by the nurse.
Here is an example of how the nurse should have documented:
Mrs. S. was ambulating to the BR with PCT. Pt. stated she “felt funny.” Pt. slowly slid
to floor with assistance. Pt. noted to turn pale white, facial grimace was fixed during
incident, contraction of large muscle of all extremities. Episode lasted 30–60 seconds.
No observation of respiratory or cardiac distress. VSS after episode (taken within 1
minute), see flowsheet. Incontinent of large amount of urine (500 cc). Speech slurred,
disoriented, and complained of tiredness for first 30 minutes following episode. No
other neurological signs affected, see Neuro flowsheet. No laceration of tongue. First
observed episode.
1 key aspects ot documentation
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Gaps in documentation on any clinical assessment tool leave the provider and
the facility open to allegations that they failed to document assessments or failed
to address significant changes of condition. In the case of an incomplete I&O, it
could be alleged that the lack of analysis, intervention, and accurate documenta-
tion was the cause of circulatory collapse, dehydration, renal failure, infections,
skin breakdown, or even death.
For the nurse to arrive at a nursing diagnosis and the development of a nursing
plan of care, the assessment findings are crucial. Be sure you develop an assess-
ment tool that assists in recording a nursing examination thoroughly, accurately,
and clearly.
Here are some risk management tips for documenting assessment findings:
Describe everything exactly as found by inspection, palpation, percussion,
or auscultation
Do not allow the use of general terms such as “normal,” “abnormal,”
“good,” or “poor”
Be specific, and include both negative and positive aspects
Ensure that your policy on assessment includes the timeframe for assess-
ment completion and documentation
Encourage the staff to document their assessment as soon as possible after
completing it
Nursing diagnosis and Nursing Outcome Classification
If nurses accurately perform the assessment process, they will be able to appropri-
ately establish nursing diagnoses. This phase of the nursing process demonstrates
that the nurse reviewed the appropriate data available at the time and made a
professional determination of the clinical problem(s) at that time. Once the nurse
makes a clinical nursing diagnosis based on a thorough assessment, the rest of the
process falls into place.
The nursing diagnosis is defined by the North American Nursing Diagnosis
Association International (NANDA International) as a “clinical judgment about the
individual, family, or community responses to actual or potential health problems
or life processes.”





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Therefore, the nursing diagnosis expresses the nurse’s professional judgment of
the patient’s clinical status, the anticipated response to treatment, and the poten-
tial nursing-care needs. It guides the nurse and subsequent providers in their
understanding of the patient’s problem(s) and the plan of care developed specifi-
cally for that problem(s).
If your organization chooses to include the nursing diagnosis in its documenta-
tion system, you should promote consistency and use of correct terminology by
adopting NANDA International terminology. The NANDA International diagnostic
headings, coupled with the patient’s clinical etiology, provide a clear picture of the
patient’s needs.
Below are some examples of nursing diagnoses.
Risk for falls: Defined by NANDA International as, “increased susceptibil-
ity to falling that may cause physical harm”
Related to neurological changes S/P seizure: The related factors are based
on the risk factors as perceived by the etiology as stated by the nurse, and
the patient’s problem
S/P grand mal seizure with neurological changes, unsteady gait
Medication for seizure control has side effects for affecting gait and bal-
ance: Based on assessment data used
History of fall within one hour of seizure, over age of 65, diminished men-
tal status: Risk factors considered by the nurse
After making the nursing diagnosis, the nurse must determine the proper outcome
for the patient.

Outcomes identification
The next step in the nursing process is to determine an expected outcome, or goal,
for the patient. The outcome must be derived from the nursing diagnosis and
documented as a measurable, realistic, and patient-focused goal. It must include
a target time or date as well as an objective measurable action that the patient is
expected to achieve.





9 key aspects ot documentation
Managing Documentation Risk, Second Edition
Whenever possible, include the patient/family’s perspective
on the goal of treatment and the timeframe. The expected out-
comes also should reflect the continuum of care, from admis-
sion, addressing immediate and intermediate outcomes, for
planning for discharge and follow-up care.
History of nursing outcomes
The use of patient outcomes in documentation dates back to
the mid-1960s, when for the first time nursing outcomes were
used to evaluate the effectiveness of nursing care. The use of
patient outcomes to evaluate healthcare dates back to Florence
Nightingale, who recorded and analyzed healthcare conditions
and the subsequent outcomes of those conditions during the
Crimean War (Moorehead 2004).
Although nurses have documented outcomes of their nursing
interventions for decades, there was no common language or associated way
to measure the outcomes of these interventions in the past. Today, however, a
research team at the University of Iowa has given nursing a standardized terminol-
ogy for nursing-specific and nursing-sensitive outcomes. This comprehensive classi-
fication of nursing outcomes is called the Nursing Outcomes Classification (NOC).
The current 2004 NOC lists 330 outcomes for use in nursing documentation. Each
NOC nursing outcome has a predetermined definition, a measurement scale, and
associated interventions. Each describes a possible state, behavior, or perception
of the patient (this is different from nursing diagnosis, which describes a patient’s
problem, either actual or potential). Once the nursing diagnosis is made the nurse
seeks to resolve it through appropriate interventions (see example in Figure 1.1).
Tips for documenting
expected outcomes:
Start with a specific action
verb that focuses on the
patient’s behavior
Avoid verbs that describe
the nurse’s behavior
(e.g., allow, let, enable)
Specify to which person
the goals refer (e.g., family,
friends)
Target dates must be realistic
Allow for flexibility of the
date if the patient needs
more time
(Goldberg 1999)





CBAÞ1lk ONl 10
Managing Documentation Risk, Second Edition
Domain-Physiologic Health (II)
Class-Cardiopulmonary (E)
Scale(s)-Severely compromised to Not compromised (a) and Severe to None (n)
Defnition: Open, clear tracheobronchial passages for air exchange
OUTCOME TARGET RATING: Maintain at________ Increase to _______
Indicators Severely
compromised
1
Substantially
compromised
2
Moderately
compromised
3
Mildly
compromised
4
Not
compromised
5
041009 Ease of breathing 1 2 3 4 5
041004 Respiratory
rate
1 2 3 4 5
041005 Respiratory
rhythm
1 2 3 4 5
041006 Moves sputum
out of airway
1 2 3 4 5
041010 Moves blockage
our of airway
1 2 3 4 5
Severe Substantial Moderate Mild None
041002 Anxiety
041011 Fear
041003 Choking
041007 Adventitious
breath sounds
2nd edition 2000; Revised 3rd edition
Reprinted from Iowa Outcomes Project: Nursing Outcomes Classifcation (NOC), 3rd edition, page 456. Copyright (2004) with permission from Elsevier.
Respiratory Status: Airway Potency (0410) Iìcuar +.+
More recently, The Joint Commission has required all hospitals and long-term
care organizations seeking accreditation to use systems that provide data about the
organization’s performance related to patient outcomes (Moorehead 2004).
A good example of the integration and use of outcomes identification can be found
in home healthcare. The Centers for Medicare & Medicaid Services (CMS) require
11 key aspects ot documentation
Managing Documentation Risk, Second Edition
all Medicare-certified home-health organizations to use the Outcome Assessment
Information Set (OASIS) data set, which they have been doing since 1998. The
OASIS outcomes system contains core measures that have been identified as appli-
cable to all client groups. It also contains measures specific to client groups with
a particular diagnosis or problem, the outcomes of which are measured on scales
specific to them. Using the OASIS outcome system, nurses assess whether home-
health clients have improved, stabilized, or deteriorated (Sparks 2001).

Planning
The next step in the nursing process is to develop a plan of care for the patient
based on the nurse’s assessment/diagnosis. Documentation of this phase demon-
strates that the clinical status of the patient was recognized and that the nurse
then developed an appropriate plan of care. It shows that the nursing process was
in place and thereby decreases the risk of incomplete or incorrect care. Having a
written “road map” helps everyone involved provide safe and quality care.
When developing a plan of care use the following guidelines:
Review identified nursing diagnoses and rank them in order of priority
Use evidence-based nursing interventions
The documentation tool/system should include nursing diagnosis, expected
outcomes, nursing interventions, and evaluation of care
The plan of care should be used as a communication tool between all
healthcare team members and the patient (Sparks 2001)
This step of the nursing process can be documented in a variety of ways. You
can use a specially designed form, flowsheet, patient-care plan, nursing progress
notes, clinical pathway, or specific software module. But whatever format is used,
remember that the patient plan of care is a permanent part of the clinical record
and must be treated as such. It should never be erased or destroyed. Adjustments
to the plan of care should reflect a progression of care based on the patient’s
needs, using the organization’s standards/protocols.





CBAÞ1lk ONl 12
Managing Documentation Risk, Second Edition
Implementation
Based on the nursing plan of care and contemporary standards of nursing care, the
nurse then documents the care provided for the patient. This phase of the nursing
process includes working collaboratively with other members of the healthcare
team, the patient, and the patient’s family.
Implementation may require some of the following interventions:
Assessing and monitoring
Therapeutic interventions
Comfort measures
Assistance with activities of daily living
Supporting respiratory functions
Supporting elimination functions
Providing skin care
Managing the environment to promote a therapeutic milieu
Providing food and fluids
Giving emotional support
Teaching and/or counseling
Referral to other agencies or services (Sparks and Taylor 2001)
Documentation will need to include the specific nurse’s intervention and the
patient’s response to the intervention. It should reflect the coordination of care,
health teaching and promotion, and any consultation that was done on behalf of
the patient. Like the documentation of planning, the documentation of care pro-
vided can be assigned to a specific form or location in the clinical record.


Evaluation
In this step of the nursing process, the nurse reviews the progress made in achiev-
ing established outcomes. The documentation needed to validate this step includes
the nurse’s comments on whether his or her assessment, diagnosis, achievement
of outcomes, plan of care, and nursing interventions were successful. In addition,
when developing a documentation system or a continuing education program for












11 key aspects ot documentation
Managing Documentation Risk, Second Edition
staff nurses, ensure that each nurse assesses the effectiveness
of the nursing process.
In determining whether the patient received high-quality care the nurse must ask
the following:
Has the patient’s condition improved, deteriorated, or remained the same?
Were the nursing diagnoses accurate?
Have the patient’s needs been met?
Did the patient meet the outcome criteria documented in the plan of care?
Do I revise or discontinue the nursing interventions?
Why did the patient fail to meet the goal? (Sparks 2001)
If the nurse uses the evaluation phase properly, the documentation will reflect
high-quality nursing care.
The graphic in Figure 1.2 shows the flow of the process and identifies the tools
associated with each phase.






CBAÞ1lk ONl 14
Managing Documentation Risk, Second Edition
ASSlSSMlN1
Definition: Subjective and objective data from
patient’s health history, physical examination,
medical record, diagnostic test results.
Tools: Physical-examination form
Consultation sheets
Nursing admission assessment
Graphic flow sheets
Flow sheet
Diagnostic test results forms
Computer software module
NUkSING oIAGNOSIS
Definition: Clinical nursing judgment based on
the assessment data.
Tools: Plan of care
Patient-care guidelines
Clinical pathways
Medication administration record
Progress notes
Problem list
Computer software module
OU1COMl IolN1IIICA1ION
Definition: Specific measurable outcome.
Tools: Nursing Outcome
Classification (NOC)
Plan of care
Clinical pathway
Computer software module
Federally mandated documentation
systems
ÞlANNING
Definition: Establish care priorities, set measur-
able goals/outcomes with target dates, describe
interventions.
Tools: Plan of care
Patient care guidelines
Clinical pathway
Discharge plan/pummary
Computer software module
IMÞllMlN1A1ION
Definition: Actual nursing interventions
delivered.
Tools: Graphic flow sheets
Flow sheets
Progress notes
Computer software module
Nursing Interventions
Classification (NIC)
lVAlUA1ION
Definition: Reassess data, nursing diagnoses, and
interventions for achievement of stated outcome.
Tools: Flow sheets
Clinical pathway
Computer software module
Nursing process fowchart Iìcuar +.z
1s key aspects ot documentation
Managing Documentation Risk, Second Edition
Organizational policies, protocols, and practices
When nurse experts are asked to review a medical record in preparation for a
legal case, they rely heavily on the medical record to determine the following:
Did the healthcare provider meet the policies and protocols of the organiza-
tion at the time of the care?
More importantly, did the healthcare provider meet the standards of nurs-
ing practice at the time of the care?
It is therefore the responsibility of the nursing management team to ensure that
the nursing staff follows the established policies of the organization and that this
compliance is demonstrated in the documentation system for that organization.
Organizational policies, protocols, and practices will always be called into review
when there is an allegation of substandard patient care. Nursing practice will be
held to national and local professional nursing standards, which are available
through the American Nurses Association (ANA) and through specialty nursing
associations such as the Association of Women’s Health, Obstetric & Neonatal
Nurses (AWHONN), Association of Perioperative Registered Nurses (AORN),
American Association of Critical-Care Nurses (ACCRN), and others. If you derive
your policies and procedures from these, your organization will be better able to
justify the care that was delivered met established professional standards.


CBAÞ1lk ONl 1õ
Managing Documentation Risk, Second Edition

Cnsr Svunv
Good documentation ret|ects tbe nursing process
Scenario: A patient complains of chest pain. Te nurse takes the patient seriously, as the subjec-
tive complaint may indicate a myocardial infarction. He or she acts quickly, performing a focused
assessment and documenting the essential information. Here are the critical elements of good
documentation of a patient with chest pain.
Documentation of what the patient said: Subjective data
2/15/07 16:00
Patient stated, “Nurse, I am having chest pain.” See Pain Flow sheet for description, loca-
tion, intensity noted. Patient in bed, increasingly anxious, used calm reassuring behavior
with patient. Redirected her to focus on remaining calm for interventions to work. Patient
responded, and pulse and respirations decreased. See VS sheet.
Te patient’s exact description of the symptom was noted, the nurse used quotations
around the patient’s words, rather than recording his or her interpretation of them.
On the pain fow sheet, the nurse indicates pain was located in the substernal region, radiat-
ing to the left shoulder. Pain level 10 out of 10. Te nurse appropriately uses the pain scale to
measure the level of intensity.
Te nurse also notes on the pain fow sheet: No preceding activity or past history of this type
of pain. Steady pain: 2-3 minutes. No SOB.
Patient care fow sheet indicated that the initial pulse and respirations at the time of the
nurse’s initial assessment of pain were
2/15/07 16:00 P:120 R: 40 BP: 146/90
2/15/07 16:04 P:96 R: 28 BP: 124/85
Documentation of what was assessed: Objective data
In the cardiopulmonary section of the patient care fow sheet, the nurse writes
SR (sinus rhythm), monitor fuctuated from S-tach to SR. No JVD.
O2 sats on RA: 92%
O2 sats on 4 L via cannula: 98%
continued on next page
11 key aspects ot documentation
Managing Documentation Risk, Second Edition

Cnsr Svunv
Good documentation ret|ects tbe nursing process (cont.)
Te nurse documents the vital signs, noting sinus tachycardia, an increased respiratory rate, and
above-baseline blood pressure for this patient. In addition, the nurse records auscultation of
heart sounds (e.g., regular, irregular heart rate, murmur, gallops, rubs.)
Te nurse assesses lung sounds and the respiratory rate and pattern, and measures abnor-
mal O2 saturation via pulse oximetry. Te patient’s actions are already noted as increasing
anxiety. Tere is no clutching of the chest by the patient. Skin assessment also is conducted
and documented.
In the cognitive section of the patient care fow sheet, the notations indicated, No changes
in mental status, no decreased level of consciousness, disorientation, or confusion.
In the narrative notes, the nurse notes, Skin cool, clammy, no peripheral edema, ashen in
color. No cyanosis noted.
Documentation of what was done: Intervention
Te nurse continues to document his or her interventions and the patient’s responses.
Frequent monitoring:
Te VSs were noted every few minutes until the chest pain subsided. Te nurse contin-
ues hourly VSs, pain assessments, and signs and symptoms of the patient.
All treatment activities are documented, including cardiac enzymes, ABG’s and EKG, SL
NTG, morphine sulfate, etc.
Fluid intake and output: Recorded every four hours.
Oxygen therapy:
Te nurse documents the patient’s initial pulse-oximetry reading, respiratory-assess-
ment fndings, and ABG results, when he or she is notifed.
Te pulse-oximetry assessments are documented every hour until within normal range,
and every four hours thereafter. Based on ABG results, O2 could be decreased.
O2 decreased to 2L
Continuous cardiac monitoring:
2/15/07 16:03 Patient placed on cardiac monitor. Patient informed as to the reason for con-
tinuous monitoring.
continued on next page






CBAÞ1lk ONl 18
Managing Documentation Risk, Second Edition

Cnsr Svunv
Good documentation ret|ects tbe nursing process (cont.)
Te nurse notes the time the patient was frst placed on the cardiac monitor (in MCL1) and
the teaching about the reason for the monitor. He or she also records which lead is being
displayed on the strip and the fow sheet. Te patient’s rhythm strip is labeled with the
patient’s name and strip intervals. Subsequent rhythm strips are obtained according to MI
protocol (such as change in condition, ectopic beats noted, or arrhythmia). Each strip has a
notation as to the heart rate and rhythm, PR-interval, and QRS-complex duration. Te pa-
tient does have a ST-segment elevation, which is noted on the strip. 2/15/07 17:02 Dr. Smith
notifed of 2mm ST elevation. New orders received and transcribed. O2 increased to 4 L, 12
lead EKG done. Stat SL NTG, Chest pain unrelieved by NTG. Morphine 2 mg. IV PRN given.
Te nurse does document notifcation of the physician for a signifcant change from the
initial strip. He or she records the physician’s response and his or her actions.
Drug and IV therapy:
Te Medication Administration Record notes the names, dosages, times, and routes of the
medications the nurse gives. Te nurse also documents the patient’s vital signs after each
dose of nitroglycerin and morphine. Te pain fow sheet indicates the patient’s response to
the NTG and morphine.
On the IV section of the patient-care fow sheet, the nurse documents his or her assess-
ment of the IV site—the date and time the IV line is inserted, catheter gauge, and person
who does the insertion. Also notes the catheter size, dressing type, and condition. During
the remainder of the shift the nurse documents his or her assessments of the IV site and line
patency.
Activity:
2/15/07 17:30 Patient informed of activity limitations due to change in her cardiac status.
Patient stated, “Don’t worry, I’ll call you before I do anything.” Te nurse notes the patient is
on bed rest and his or her instructions regarding patient-activity limitations.
Communication:
Te nurse is good at documenting his or her communication with other healthcare team
members. It is found in his or her narrative notes, names, time of notifcation, etc.
continued on next page
19 key aspects ot documentation
Managing Documentation Risk, Second Edition

Cnsr Svunv
Good documentation ret|ects tbe nursing process (cont.)
Emotional support:
2/15/07 20:10 Patient increasing in anxiety, attempted to get the patient to talk about her
feelings. Ofered medication to assist in decreasing her anxiety. Patient agreed to medication.
Te nurse ofers and documents emotional support to help the patient cope with the physi-
cal and psychological impact of her condition.
Transfer to ICU:
Tis patient does not need to be transferred, but if she had, the nurse would have docu-
mented the aspects of the patient’s condition that warranted the transfer. Te report to the
ICU nurse would have been documented and, if applicable, a written record of the patient’s
belongings would have been included. Te nurse also would have recorded the name of the
person who accompanied the patient and which monitoring devices were in place during
the transport. Someone would have to document how well she tolerated the transfer.
Documentation of what was taught
Te teaching plan needs to be tailored to the patient’s condition and treatment. Documentation
of patient/family teaching needs to include what was taught, the method of teaching, the materi-
als used for teaching, how well the patient/family understood the teaching, etc.
In this case, nurses discuss the following with this patient:
Heart anatomy and physiology
Disease process
Diagnostic tests and the reason for them
Treatment options such as angioplasty, stents, or thrombolytics
Signs and symptoms of an MI
Signs and symptoms to report
Actions to take when chest pain returns
Medication management (i.e., prescribed drugs and their names, dosages,
times to take them, route, any potential side efects, and how to store the medications)
Smoking cessation advice
Diet management
Activity and rest patterns
Community support groups, cardiac rehab centers (Sparks 2001)













CBAÞ1lk ONl 20
Managing Documentation Risk, Second Edition
krrrarucrs
Goldberg, K. 1999. Surefre Documentation: How, What, and When Nurses Need to Document Philadel-
phia: Mosby, Inc.
Mosby. Mosby’s Surefre Documentation: How, What, and When Nurses Need to Document, 2nd edition.
Philadelphia: Mosby, Inc.
Irving, K. et al. 2006. “Discursive practices in the documentation of patient assessments.” Journal of Ad-
vanced Nursing 53(2): 151-159.
Moorhead, S. et al. 2004. Iowa Outcomes Project Nursing Outcomes Classifcation (NOC), 3rd edition, St.
Louis: Mosby.
Sparks, S. and C. Taylor. 2001. Nursing Diagnosis Reference Manual, 5th edition. Springhouse, PA: Spring-
house Corp.

Managing Documentation Risk
A Guide for Nurse Managers
Patricia A. Duclos-Miller MS, RN, CNA, BC SECO N D E D I T I O N

Managing Documentation Risk: A Guide for Nurse Managers, Second Edition is published by HCPro, Inc. Copyright ©2007, 2004 HCPro, Inc. All rights reserved. Printed in the United States of America. First edition published 2004. Second edition 2007. ISBN 978-1-60146-036-3 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Patricia A. Duclos-Miller, MS, RN, CNA, BC, Author Rebecca Hendren, Senior Managing Editor Jamie Gisonde, Executive Editor Emily Sheahan, Group Publisher Janell Lukac, Layout Artist Liza Banks, Proofreader Darren Kelly, Books Production Supervisor Susan Darbyshire, Art Director Claire Cloutier, Production Manager Jean St. Pierre, Director of Operations 5 4 3 2 1

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. P.O. Box 1168 Marblehead, MA 01945 Telephone: 800/650-6787 or 781/639-1872 Fax: 781/639-2982 E-mail: customerservice@hcpro.com Visit HCPro at its World Wide Web sites: www.hcpro.com and www.hcmarketplace.com 5/2007 21196

Second Edition . Her editorial skills added tremendously to the value of the book. Managing Documentation Risk. who have always supported my endeavors.Dedication iii Dedication To my family. Acknowledgement A sincere thank you to my editor who made this book a pleasure to revise.

..............................................................................47 State Nurse Practice Act.........................................................................................................................................................................................37 Chapter three Contemporary nursing practice: Are you and your staff there? ................................................................................................................................................................................................................................................................................................................................25 Case Study: Incomplete documentation ...........................................................................................................................................................36 Risk-reduction recommendations for nurse managers ........................................................................................................................................................................................................................................................................50 Managing Documentation Risk...................................................................................................................................................21 Your documentation: Truth or consequences? ............................................................................................................................................................................................................................................................................................................................................................................................. 2 Let the nursing process be your guide ..................................................................26 Case Study: Improperly altered documentation ....................................... 1 Nurse manager responsibilities ...............................................16 Chapter tWo Reducing risk and culpability through defensive documentation ......................................................................................................................................................................................................................................12 Organizational policies.............. 3 Nursing diagnosis and Nursing Outcome Classification ......28 Case Study: Neglected documentation II ....................................................................................................................................................................................................................................................... 1 What every nurse manager needs to know .................................................................................................................................................................................................................................................................30 Adverse events: When bad things happen to good nurses .........................................................................................................23 The consequences ........................................................................ 8 Planning ........................21 Case Study: The truth comes out .....................................................................................................................................11 Implementation .......................................................................................................... ix Chapter one Key aspects of documentation ................................................................................12 Evaluation......................21 The truth................41 Are you using contemporary nursing practice?...................................................................................................................................................................................................................................................................................................................................................................35 Tips for writing an incident report ..................................................................31 Documentation of adverse events .......................................................29 Handling documentation errors .......................................33 Incident reports ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................viii Introduction ..........................................Chapter one ContentS About the author..............................................................41 Certification ...................................................... Second Edition ................................................................................................................................. protocols.................................................................................................................................................................................................................................................................................................15 Case Study: Good documentation reflects the nursing process ......................................................................................................23 Risk-management guidelines for documenting care ...............................................................................................48 Threats to licensure ................................................................................................................................................................................................................................................................................................ 7 Outcomes identification ..................... and practices ....................................................................................................................................................................................................................................................24 Case Study: Neglected documentation ................43 Code of ethics .....42 Professional standards ......

..............................................................................104 Chapter SeVen Improving staff documentation .................................................................................61 The Joint Commission and “tracer methodology” ..........................................................................................................................................81 Case Study: Incompetent care ...................................111 Recognizing and correcting charting mistakes that increase your liability risks .......................................................................77 Essential definitions ......Contents Federal and state regulations.........................................................................................................................................................................................92 Chapter SIX Depositions: Preparing for the worst ................................95 Meeting with your organization’s attorney/risk manager............95 When it happens to you............................................................................................................................................................................96 Reviewing medical records and all associated policies.......................................................................56 Chapter FoUr  Functions of the medical record .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................87 Case Study: Failure to follow protocol...............54 Resources ................................................ prepare .....................................................111 Eight common charting errors ............................................................89 Case Study: Failure to properly orient............................................................................................................ and evaluate ............... prepare............................................................102 At the deposition ......................................................79 Legal risks for nurse managers ...............................................................................112 Case Study: Failure to record medication given .........................................................................................................................103 Tips for presenting an effective deposition testimony...............................51 The Joint Commission ...............................................................................................................................................................................................64 Quality and risk-management review ........................................................69 Resources .................................................................................................................90 National Practitioner Data Bank ...........................97 The importance of a deposition................................................................113 Managing Documentation Risk.....99 The players ................................................................................................................. and reimbursement............... quality......................................................................................................................90 Liability in special practice settings................................................................................................................................................................................................................95 Essential definitions ....................................................................................77 Legal issues............................................................................................................................................77 Factors that contribute to malpractice cases against nurses .....................59 The effects of staff documentation on compliance......................................................................... educate..........100 Prepare..................86 Case Study: Chart review reveals fraudulent countersignature ...................................59 Medical record as communication ................................................................................................ Second Edition ....................................................88 Case Study: Breach in nursing standard of practice...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................59 Medical record as a demonstration of compliance ................................................................75 Chapter FIVe Nursing negligence: Understanding your risks and culpability .............................................................................................................................................................................................................................................................................................................................................................................................68 Medical record as a path to reimbursement ................................................................................................................................................................................................................................................................................................................................54 Organizational policies and procedures................................................................87 Professional-negligence claims against nurses .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................85 Legal risks for nurses ..................................................................................................................................................................................................................................................

...............................................................153 Why we need electronic health records ................................................................................................................................................................................................................................................................................................................................................................179 Continuing education exam..............155 The nurse manager’s role.................................................................................................................................................119 Chapter eIGht Developing a foolproof documentation system....................147 The important role audits play in protecting you and your organization ..........................................................175 Nursing education instructional guide .137 10 steps for building a foolproof documentation system ....................................................................................................................................................................................................................169 The good.......................................................................................................................................................142 Chapter nIne Auditing your documentation system .......... and the ugly approach ..... the bad................................................147 Measuring compliance and improvement through an audit ..................................................156 Challenges associated with the change ..........................................................................149 Getting your staff to use the audit tool ........192 Managing Documentation Risk................................................171 Staff-motivation tips for nurse managers ...........................................................................................................118 Tips to improve your staff’s documentation .....................................................................................................................................................................................................................157 Computer etiquette .............................................................................................................................................................................................................................................................................................................................................................................................167 The role of education and expectations .........................................173 appenDIX Sample audit tools ......150 Advantages of audits for the nurse manager.......................................................................................................................................................................................................................................................................................................................................................................................................................................159 Strategies for success .......................................................................................147 Building your audit system around performance-improvement goals ........165 Why nurses document poorly ..........................................................................151 Chapter ten Electronic health records ..................165 Change: Embrace it or resist it ............................................................................................................................................................................................125 Systems of documentation ......................................161 Chapter eLeVen Motivating your nurses to document completely and accurately............................................... Second Edition ...........................................................................................................................................................................................................................................................................................................125 Evaluating your current documentation system ..........................................................................................117 The consequences of an incomplete medical record................................................................127 Using The Joint Commission standards as the foundation of your system ..............................................................i Contents Other common charting flaws ................................................................................................................................................................................................................................................................183 Continuing education evaluation .................................................................................154 Benefits of electronic documentation ................................154 Start at the beginning .......................................................................................................................................................................................................................................................................................................................................................................................................................................153 Nurse managers’ roles in building a computerized system that reduces liability................................................................................151 Nurse manager tips for auditing .........................................................................................................................125 Building on the foundation of compliance standards ........................170 Monitoring the work environment .................................................................................................................................

.....................................................................................1 POMR example..........................1 Nurse manager risk-management checklist for adverse events......72 Figure 5.................................................................................................................................................................5 Example of outcome criteria.....................131 Figure 8......1 Figure 1..............................................................................................3 HIPDB reports on organizations .................3 Respiratory Status: Airway patency (0410).......42 ANA Standards of Nursing Practice..............................................138 Figure 9.............8 Nursing department—Medical record audit (based on The Joint Commission standards) ........................134 Figure 8...2 Example of nursing progress notes using PIE .......................46 The Joint Commission hospital measure set ...........128 Figure 8.........................137 Figure 8.........................................................................................................136 Figure 8..............................................................................130 Figure 8.......................................................................................................................1 Steps in the quality improvement process .......................... Second Edition ..........................................................................................2 Figure 3............................1 Transforming a gripe into a goal in five minutes ......................14 Quiz: Do I need to report this? ...............................................1 Illegible-clinical-documentation policy.................................................84 Figure 5..............................................................................................................3 Example of focus charting ..............................................................148 Figure 11...............116 Figure 7.........1 Figure 3........32 Contemporary nursing practice self-assessment....................................................................91 Figure 5................................................45 ANA Standards of Practice for Nurse Administrators ...................................................................................................................................177 Figure 1...........................................................66 Compliance chart review table.....................................................................................................................................................7 Comparison of charting systems .........................................................FIGUreS CMS Quality Measures...........129 Figure 8..........2 Illegible-documentation reporting form ..........................................176 Appendix III Sample pain assessment audit tool ....2 Figure 2...................................92 Figure 7.................................................175 Appendix II Sample ED documentation audit tool .....10 Nursing process flowchart..........................117 Figure 8...............................................4 Example of CBE assessment standards ..........................................................2 National Practitioner Data Bank (NPDB) Summary Report ......................................................2 Figure 4..........................................3 Figure 4.............................................................................................6 Audit tool to evaluate nursing process.......1 Figure 4.172 Appendix I Sample post-fall audit ....68 Managing Documentation Risk.................................................................1 Figure 3.......................................................................

Duclos-Miller. Inc. and long-term care settings. CNA. In addition to this position. the first and second editions of Managing Documentation Risk: A Guide for Nurse Managers. and neonatal intensive care nursing. Duclos-Miller has served in key leadership positions for professional nursing organizations and is a contributor to the newsletter Strategies for Nurse Managers. CT. team building. a special lecturer for the University of Connecticut’s management in nursing graduate program. Second Edition . and a staff nurse in the specialties of medical-surgical. CT. CNA. MS. BC Patricia A. Duclos-Miller is a registered nurse. CT. She is the author of Stressed Out About Your First Year of Nursing. and documentation issues. RN. all published by HCPro. she is a senior consultant for the Kelsco Consulting Group in Cheshire. Managing Documentation Risk. and the first and second editions of the handbook Nursing Documentation: Reduce Your Risk of Liability. home health. she has been a director for quality improvement. BC is currently a full-time associate professor in nursing at Capital Community College in Hartford. published by HCPro. During her 33 years in nursing. She is a recognized speaker on contemporary nursing topics. director of nursing in acute.aBoUt the aUthor Patricia A. including quality improvement. RN. and a per diem supervisor at Bristol Hospital. Duclos-Miller. Inc. MS. board certified by the American Nurses Credentialing Center (ANCC) in nursing administration. mother-baby.

Second Edition . in matters of alleged negligence. complete. You must protect yourself. In today’s fast-paced world with its shrinking nursing staff. because nursing management staff bear the burden of endorsing the facility’s policies and protocols and ensuring that the care rendered is up-to-date. external and internal qualityimprovement monitors.” As much as we might cringe at the saying. timely. delivered. This assumption dates back to the time of Florence Nightingale. When reviewed. and. If the medical record does not reflect what happened. Documentation is especially important for directors. a complete and accurate clinical record must reflect that quality care was. when “push comes to shove” during a busy day. However. a documentation system needs to be efficient. patients themselves and their attorneys. who viewed documentation as a vital part of professional practice. it didn’t happen. This record is reviewed by payers. and nursing supervisors. but it becomes a foe if there are gaps. and meets the standards of practice. the medical record must demonstrate that the patient received the best. It is critical that you recognize that documentation is an important part of everyday work for Managing Documentation Risk. most appropriate care possible. whatever is written in the medical record—not what you claim—will be considered the truth. in fact.IntroDUCtIon Healthcare professionals acknowledge that documentation is an essential component of good patient care. the door is open for a claim of poor quality or questions about whether the appropriate care was administered. your staff. When patient care is reviewed. Every professional must reexamine his or her commitment to safe patient care and place documentation at the top of the priority list. This possibility leads us to the old adage. and your organization against claims of poor quality care. Documentation can be a friend if the medical record clearly outlines the details of care. regulatory and accrediting agencies. “If it wasn’t documented. documentation often becomes the least-valued aspect of care. and complete. timely. nurse managers.

decrease their culpability in any potential legal cases. your efforts to improve documentation will be not be successful. and development and design of a user-friendly documentation system. and assist in decreasing the likelihood that their subordinates will be cited in a medical or nursing malpractice case. Second Edition . how to improve documentation. The following chapters will provide you with an understanding of why documentation is crucial. This book is a critical tool for anyone in nursing management who would like to improve the quality of patient care. your endorsement needs to be visible. Introduction physicians. and other healthcare providers. nurses. the medical record is a reflection of the care administered. you will have to design an ongoing audit system to evaluate and measure compliance. As part of nursing management. what makes a case vulnerable to legal recourse. Once the documentation system and tools are in place. You and your staff need the nursing documentation to speak for itself. continuing education concerning documentation. Remember. Managing Documentation Risk. and it will always stand on its own merits. you must also be knowledgeable in the legal aspects of nursing. To protect yourself and your staff from liability. and how to motivate your staff to a level of excellence that is reflected in the medical record. in the form of ongoing collaborative case reviews. If you do not see the value of what is needed in the medical record. It is read by all those with rights to view it.

its content is regulated by the state in which you practice. you must assume responsibility for ensuring complete and accurate documentation. In addition. so you need to accept the responsibility whether it is part of your job description or not.Chapter one Key aspects of documentation Learning objectives After reading this chapter. It is used by the system’s quality and risk-management department and the utilization-management committee. the accuracy and completeness of the clinical record is essential to healthcare researchers. and reviewed for compliance with accreditation standards. Documenting completely and accurately is considered a professional standard of nursing practice. It is also vital that you assist staff in practicing defensive documentation and in avoiding the potential for legal consequences if a case is reviewed for alleged medical malpractice. it supplies other care providers with consistent. The medical record must be accurate and complete because the information it contains is critical for a number of people and functions. your title and scope of responsibilities will bring under scrutiny your commitment to safe and quality patient care. It is also referred to when professional care rendered was considered negligent. In some cases. You must recognize the importance of good clinical documentation. clear communication and validates critical decision-making that is often necessary for quality patient care. Managing Documentation Risk. In today’s culture of accountability. The nurse manager must assist nurses in fulfilling the necessary requirements of good clinical care and documentation. It is used to communicate patients’ programs to other staff and the various clinical and ancillary departments involved in their care. audited by insurers (both private and public). the participant will be able to: • Discuss how the nursing process is used in nursing documentation • Describe how to use Nursing Outcomes Classification (NOC) in nursing documentation What every nurse manager needs to know As a member of a nursing management team. the care delivered must be documented. For every step in the nursing process. Second Edition . Doing so not only validates the universally recognized professional approach to patient care.

In addition. your ability to manage and meet quality and risk-management standards will be called into question. The quality of the care provided to patients can only be measured by the quality of the nursing documentation. Chapter one There are many research studies that have attempted to identify why nurses do not value the importance of their documentation. Incomplete documentation allows for juries to conclude that the nurse did not: • Collect sufficient data and plan appropriate care • Implement appropriate interventions. It is to your advantage to fulfill these responsibilities because if your staff is involved in a medical malpractice case. Managing Documentation Risk. it can be used to support an allegation that negligent care was provided. If documentation is incomplete. It is also your responsibility to provide continuing education. What is still missing with these changes is the failure to demonstrate patient continuity of care and the evaluation of patient outcomes (Irving 2006). or is not consistently completed according to the organization’s policies. and input into policy and documentation-system changes whenever possible. One study by Moody and Snyder claims an estimated 15-20% of the nursing work time is spent in documentation. Second Edition . The major reasons for documenting nursing care include: • Documentation of the plan of nursing care • Evaluation of the effectiveness of the nursing care provided • Facilitation of communication between the patient/family and other providers Failure to completely document can have legal consequences. professional feedback. according to professional and institutional standards • Make good clinical decisions • Communicate effectively Nurse manager responsibilities As a nurse manager. contains gaps. documentation has changed over the last few decades in both its appearance and the advent of new technology. it is your responsibility to assist staff in adhering to both clinical and documentation standards.

policies. your documentation of patient care should follow the framework of the nursing process. it is equally important to ensure that they document that compliance accurately and completely. the physical exam. The language should include stipulations for daily supervisory oversight. which could include the patient’s history. smelled. the chief complaint. you must not only demonstrate a commitment to providing safe and efficient patient care. So as not to become overwhelmed. • Emphasizing the importance of documentation through written guidelines. That is. and feedback to the staff. but also ensure that every clinical record reflects that commitment. Second Edition . Not only does each step guide us in our approach. For example.  Let the nursing process be your guide The nursing process. as outlined by the American Nurses Association (ANA) Nursing Scope and Standards of Practice. and did while providing that care. the nurse must decide which information is most useful to the care of the patient. The process accounts for all significant data and actions taken by a registered nurse. and so on. • Involving the end users in the development of the system. heard. laboratory data. it tells us how to validate what we saw. scientific approach to providing nursing care. audits of the system. or medical diagnosis. Nursing management can demonstrate support for such a system by: • Developing an efficient system that meets the requirements of regulatory standards. provides us with an established. the documentation of which is used for critical decision-making. a nurse could limit the assessment data to the admission signs and symptoms. said. felt. In this step.Key aspects of documentation As a member of the nursing-management team. This first step in Managing Documentation Risk. the nurse collects information about the patient’s condition. Assessment The first step of the nursing process is assessment. Your role is to support an efficient and effective documentation system and to create an expectation that the system be followed. job descriptions. Therefore. and performance appraisals. although you must ensure that nursing staff comply with up-to-date standards.

Objective data Nurses establish patients clinical status based on objective data. beware of inappropriate documentation practices and focus on risk management. Subjective data In this context. If the objective data is not reviewed in a timely manner. Statements made by the patient or family/significant other are examples of subjective data. there will be times when a patient’s words need to be recorded to establish a clear picture of how the patient perceives his or her status. and auscultation. documentation of the conversation can be used to measure progress or decline over the course of treatment. For instance. subjective data are data that can be observed. a reviewer of the clinical record may point out that you failed to interpret the data and address significant changes of condition. but not measured. which include key assessment techniques such as inspection. There also may be situations in which critical objective data were present but there was no subsequent documentation of an appropriate intervention. Second Edition . behavioral. nurses’ objective assessment is based on what is seen. nonverbal cues are essential in determining whether there has been any change in status. In simpler terms. When documenting this data. there are risks your staff should consider. felt and smelt. Chapter one the nursing process—assessment—should always be evident in the medical record as it provides a complete clinical picture of the patient. heard. These conversations with the patient/family will need to be captured in the clinical record in order to provide other clinicians with an accurate depiction of the patient’s current status. provide objective data about patients’ health status. palpation. or cognitive status at the time of the assessment. Managing Documentation Risk. An assessment should include both subjective and objective data. Physical exam of patients. percussion. however. If patients are unable to speak or are cognitively impaired. which are observable and measurable. When recording this data. Healthcare providers find this much easier to validate and include in their documentation than subjective data. Although every conversation may not be relevant to the interaction. if the patient says something that can be used to demonstrate mental. Objective data also includes the results of diagnostic tests.

visual.  Unacceptable assessment documentation When documenting subjective or objective data. or something else? Lack of documentation of a complete neurological assessment can lead to an accusation of failure to document assessments according to contemporary nursing standards. Coma Scale. The following examples of entries into the medical record illustrate several common mistakes: 1. cranial nerve. it may contribute to a lack of appropriate intervention identification. Managing Documentation Risk. if the absence of critical objective data resulted in a gap in the clinical picture of the patient. All of these situations can lead to quality and risk-management issues. Second Edition .Key aspects of documentation In addition. musculoskeletal. be careful to do so thoroughly and appropriately. The solution: Develop a neurological assessment tool that is based on current standards and ensure that staff complete the tool according to the policy and documentation guidelines. The entry: Neuro signs WNL The problem: Which aspects of the neurological assessment are within normal limits (WNL)? Does “WNL” refer to cognitive.

Incomplete I&O sheets can lead to allegations of improper assessment and insufficient data gathering. which resulted in the patient being harmed. S. disoriented. or physical change during the seizure. and quantities measured for both intake and output. Incontinent of large amount of urine (500 cc). and complained of tiredness for first 30 minutes following episode. No laceration of tongue. times. color. contraction of large muscle of all extremities. Start by documenting the patient’s status prior to the incident. The solution: Ensure that all I&O sheets are completed in their entirety. First observed episode. see Neuro flowsheet. It is the nurse’s responsibility to give a complete clinical description of the incident so that any reader can visualize what happened. VSS after episode (taken within 1 minute). if known. Chapter one 2. Second Edition . Describe any report of an aura. No observation of respiratory or cardiac distress. facial grimace was fixed during incident. Episode lasted 30–60 seconds. noted to turn pale white. No other neurological signs affected. Record the length of time of the seizure and the condition of the patient immediately following it. see flowsheet. middle. Here is an example of how the nurse should have documented: Mrs. Speech slurred. Check for accurate dates. posturing.” Pt. 3. including both subjective data (what did the patient tell you about the incident?) and objective data (what were his or her vital and neurological signs?) assessed by the nurse. The entry: Grand mal seizure The problem: This is not a complete assessment. The solution: Ensure that your documentation of this episode has a beginning. The entry: [Incomplete I&O sheet] The problem: Incomplete intake and outtake (I&O) sheets. was ambulating to the BR with PCT. It could then be argued that these omissions led to a lack of decision-making. slowly slid to floor with assistance. Pt. stated she “felt funny. and end. Managing Documentation Risk. Pt.

For the nurse to arrive at a nursing diagnosis and the development of a nursing plan of care. Once the nurse makes a clinical nursing diagnosis based on a thorough assessment. palpation. or community responses to actual or potential health problems or life processes.Key aspects of documentation Gaps in documentation on any clinical assessment tool leave the provider and the facility open to allegations that they failed to document assessments or failed to address significant changes of condition. skin breakdown. renal failure. In the case of an incomplete I&O.” “abnormal. and accurate documentation was the cause of circulatory collapse. The nursing diagnosis is defined by the North American Nursing Diagnosis Association International (NANDA International) as a “clinical judgment about the individual. family. intervention. percussion. infections. accurately.” “good. the rest of the process falls into place. the assessment findings are crucial. they will be able to appropriately establish nursing diagnoses. or auscultation • Do not allow the use of general terms such as “normal. This phase of the nursing process demonstrates that the nurse reviewed the appropriate data available at the time and made a professional determination of the clinical problem(s) at that time.” Managing Documentation Risk. and include both negative and positive aspects • Ensure that your policy on assessment includes the timeframe for assessment completion and documentation • Encourage the staff to document their assessment as soon as possible after completing it  Nursing diagnosis and Nursing Outcome Classification If nurses accurately perform the assessment process. and clearly. or even death. Here are some risk management tips for documenting assessment findings: • Describe everything exactly as found by inspection.” or “poor” • Be specific. Be sure you develop an assessment tool that assists in recording a nursing examination thoroughly. it could be alleged that the lack of analysis. dehydration. Second Edition .

Below are some examples of nursing diagnoses. The NANDA International diagnostic headings. Managing Documentation Risk. Chapter one Therefore. the nurse must determine the proper outcome for the patient. realistic. provide a clear picture of the patient’s needs. the anticipated response to treatment. coupled with the patient’s clinical etiology. • Risk for falls: Defined by NANDA International as. Outcomes identification The next step in the nursing process is to determine an expected outcome. or goal. It guides the nurse and subsequent providers in their understanding of the patient’s problem(s) and the plan of care developed specifically for that problem(s). and the patient’s problem • S/P grand mal seizure with neurological changes. If your organization chooses to include the nursing diagnosis in its documentation system. “increased susceptibility to falling that may cause physical harm” • Related to neurological changes S/P seizure: The related factors are based on the risk factors as perceived by the etiology as stated by the nurse. unsteady gait • Medication for seizure control has side effects for affecting gait and balance: Based on assessment data used • History of fall within one hour of seizure. and the potential nursing-care needs. the nursing diagnosis expresses the nurse’s professional judgment of the patient’s clinical status. The outcome must be derived from the nursing diagnosis and documented as a measurable. you should promote consistency and use of correct terminology by adopting NANDA International terminology. and patient-focused goal. Second Edition . for the patient. diminished mental status: Risk factors considered by the nurse After making the nursing diagnosis. It must include a target time or date as well as an objective measurable action that the patient is expected to achieve. over age of 65.

Although nurses have documented outcomes of their nursing interventions for decades. from admission.. The current 2004 NOC lists 330 outcomes for use in nursing documentation. however. Today. either actual or potential). allow. there was no common language or associated way to measure the outcomes of these interventions in the past.g. enable) • Specify to which person the goals refer (e. or perception of the patient (this is different from nursing diagnosis.Key aspects of documentation Whenever possible. The expected outcomes also should reflect the continuum of care. a measurement scale. addressing immediate and intermediate outcomes. Second Edition . family. who recorded and analyzed healthcare conditions and the subsequent outcomes of those conditions during the Crimean War (Moorehead 2004).g. The use of patient outcomes to evaluate healthcare dates back to Florence Nightingale.  Tips for documenting expected outcomes: • Start with a specific action verb that focuses on the patient’s behavior • Avoid verbs that describe the nurse’s behavior (e. friends) • Target dates must be realistic • Allow for flexibility of the date if the patient needs more time (Goldberg 1999) History of nursing outcomes The use of patient outcomes in documentation dates back to the mid-1960s. for planning for discharge and follow-up care.1). a research team at the University of Iowa has given nursing a standardized terminology for nursing-specific and nursing-sensitive outcomes. Each NOC nursing outcome has a predetermined definition. which describes a patient’s problem. behavior. and associated interventions. Once the nursing diagnosis is made the nurse seeks to resolve it through appropriate interventions (see example in Figure 1. Managing Documentation Risk.. Each describes a possible state. include the patient/family’s perspective on the goal of treatment and the timeframe. when for the first time nursing outcomes were used to evaluate the effectiveness of nursing care. This comprehensive classification of nursing outcomes is called the Nursing Outcomes Classification (NOC). let.

Revised 3rd edition Reprinted from Iowa Outcomes Project: Nursing Outcomes Classification (NOC). The Joint Commission has required all hospitals and long-term care organizations seeking accreditation to use systems that provide data about the organization’s performance related to patient outcomes (Moorehead 2004). page 456. More recently. Second Edition .10 Chapter one Figure 1. Copyright (2004) with permission from Elsevier. The Centers for Medicare & Medicaid Services (CMS) require Managing Documentation Risk. clear tracheobronchial passages for air exchange OUTCOME TARGET RATING: Maintain at________ Increase to _______ Indicators Severely compromised 1 1 1 Substantially compromised 2 2 2 Moderately compromised 3 3 3 Mildly compromised 4 4 4 Not compromised 5 5 5 041009 041004 Ease of breathing Respiratory rate Respiratory rhythm Moves sputum out of airway Moves blockage our of airway 041005 1 2 3 4 5 041006 1 2 3 4 5 041010 1 2 3 4 5 Severe 041002 041011 041003 041007 Anxiety Fear Choking Adventitious breath sounds Substantial Moderate Mild None 2nd edition 2000.1 Respiratory Status: Airway Potency (0410) Domain-Physiologic Health (II) Class-Cardiopulmonary (E) Scale(s)-Severely compromised to Not compromised (a) and Severe to None (n) Definition: Open. 3rd edition. A good example of the integration and use of outcomes identification can be found in home healthcare.

clinical pathway. nursing interventions. nursing progress notes. Using the OASIS outcome system. 11 Planning The next step in the nursing process is to develop a plan of care for the patient based on the nurse’s assessment/diagnosis. flowsheet. The OASIS outcomes system contains core measures that have been identified as applicable to all client groups. using the organization’s standards/protocols. Managing Documentation Risk. But whatever format is used. the outcomes of which are measured on scales specific to them. and evaluation of care • The plan of care should be used as a communication tool between all healthcare team members and the patient (Sparks 2001) This step of the nursing process can be documented in a variety of ways. It also contains measures specific to client groups with a particular diagnosis or problem. or deteriorated (Sparks 2001). Documentation of this phase demonstrates that the clinical status of the patient was recognized and that the nurse then developed an appropriate plan of care. Second Edition . Adjustments to the plan of care should reflect a progression of care based on the patient’s needs. or specific software module. remember that the patient plan of care is a permanent part of the clinical record and must be treated as such. It shows that the nursing process was in place and thereby decreases the risk of incomplete or incorrect care. stabilized. which they have been doing since 1998. expected outcomes. You can use a specially designed form. It should never be erased or destroyed. nurses assess whether homehealth clients have improved. patient-care plan.Key aspects of documentation all Medicare-certified home-health organizations to use the Outcome Assessment Information Set (OASIS) data set. Having a written “road map” helps everyone involved provide safe and quality care. When developing a plan of care use the following guidelines: • Review identified nursing diagnoses and rank them in order of priority • Use evidence-based nursing interventions • The documentation tool/system should include nursing diagnosis.

Second Edition . achievement of outcomes. the nurse reviews the progress made in achieving established outcomes. Implementation may require some of the following interventions: • Assessing and monitoring • Therapeutic interventions • Comfort measures • Assistance with activities of daily living • Supporting respiratory functions • Supporting elimination functions • Providing skin care • Managing the environment to promote a therapeutic milieu • Providing food and fluids • Giving emotional support • Teaching and/or counseling • Referral to other agencies or services (Sparks and Taylor 2001) Documentation will need to include the specific nurse’s intervention and the patient’s response to the intervention. plan of care. This phase of the nursing process includes working collaboratively with other members of the healthcare team. It should reflect the coordination of care. In addition. Like the documentation of planning. and the patient’s family.1 Chapter one Implementation Based on the nursing plan of care and contemporary standards of nursing care. diagnosis. health teaching and promotion. and any consultation that was done on behalf of the patient. The documentation needed to validate this step includes the nurse’s comments on whether his or her assessment. the patient. Evaluation In this step of the nursing process. and nursing interventions were successful. the documentation of care provided can be assigned to a specific form or location in the clinical record. the nurse then documents the care provided for the patient. when developing a documentation system or a continuing education program for Managing Documentation Risk.

or remained the same? • Were the nursing diagnoses accurate? • Have the patient’s needs been met? • Did the patient meet the outcome criteria documented in the plan of care? • Do I revise or discontinue the nursing interventions? • Why did the patient fail to meet the goal? (Sparks 2001) If the nurse uses the evaluation phase properly. The graphic in Figure 1.Key aspects of documentation staff nurses.2 shows the flow of the process and identifies the tools associated with each phase. 1 Managing Documentation Risk. ensure that each nurse assesses the effectiveness of the nursing process. Second Edition . In determining whether the patient received high-quality care the nurse must ask the following: • Has the patient’s condition improved. deteriorated. the documentation will reflect high-quality nursing care.

Second Edition .1 Chapter one Figure 1. diagnostic test results. Tools: Plan of care Patient care guidelines Clinical pathway Discharge plan/pummary Computer software module IMpLeMentatIon Definition: Actual nursing interventions delivered. Tools: Nursing Outcome Classification (NOC) Plan of care Clinical pathway Computer software module Federally mandated documentation systems pLannInG Definition: Establish care priorities. Tools: Plan of care Patient-care guidelines Clinical pathways Medication administration record Progress notes Problem list Computer software module oUtCoMe IDentIFICatIon Definition: Specific measurable outcome. medical record. physical examination. Tools: Flow sheets Clinical pathway Computer software module Managing Documentation Risk. and interventions for achievement of stated outcome. set measurable goals/outcomes with target dates. describe interventions. nursing diagnoses.2 Nursing process flowchart aSSeSSMent Definition: Subjective and objective data from patient’s health history. Tools: Graphic flow sheets Flow sheets Progress notes Computer software module Nursing Interventions Classification (NIC) eVaLUatIon Definition: Reassess data. Tools: Physical-examination form Consultation sheets Nursing admission assessment Graphic flow sheets Flow sheet Diagnostic test results forms Computer software module nUrSInG DIaGnoSIS Definition: Clinical nursing judgment based on the assessment data.

your organization will be better able to justify the care that was delivered met established professional standards. Association of Perioperative Registered Nurses (AORN).Key aspects of documentation 1 Organizational policies. American Association of Critical-Care Nurses (ACCRN). and others. did the healthcare provider meet the standards of nursing practice at the time of the care? It is therefore the responsibility of the nursing management team to ensure that the nursing staff follows the established policies of the organization and that this compliance is demonstrated in the documentation system for that organization. Nursing practice will be held to national and local professional nursing standards. which are available through the American Nurses Association (ANA) and through specialty nursing associations such as the Association of Women’s Health. and practices will always be called into review when there is an allegation of substandard patient care. If you derive your policies and procedures from these. Second Edition . protocols. Obstetric & Neonatal Nurses (AWHONN). they rely heavily on the medical record to determine the following: • Did the healthcare provider meet the policies and protocols of the organization at the time of the care? • More importantly. Managing Documentation Risk. protocols. Organizational policies. and practices When nurse experts are asked to review a medical record in preparation for a legal case.

and pulse and respirations decreased. The patient’s exact description of the symptom was noted. The nurse appropriately uses the pain scale to measure the level of intensity. On the pain flow sheet. Pain level 10 out of 10. the nurse writes SR (sinus rhythm). O2 sats on RA: 92% O2 sats on 4 L via cannula: 98% continued on next page Managing Documentation Risk. as the subjective complaint may indicate a myocardial infarction. Patient responded. rather than recording his or her interpretation of them. used calm reassuring behavior with patient.1 Chapter one Good documentation reflects the nursing process Scenario: A patient complains of chest pain. Patient in bed. intensity noted. increasingly anxious. The nurse takes the patient seriously. Here are the critical elements of good documentation of a patient with chest pain. No SOB. No JVD. radiating to the left shoulder.” See Pain Flow sheet for description. Patient care flow sheet indicated that the initial pulse and respirations at the time of the nurse’s initial assessment of pain were 2/15/07 16:00 P:120 R: 40 BP: 146/90 2/15/07 16:04 P:96 R: 28 BP: 124/85 Case Study Documentation of what was assessed: Objective data In the cardiopulmonary section of the patient care flow sheet. I am having chest pain. Steady pain: 2-3 minutes. Redirected her to focus on remaining calm for interventions to work. See VS sheet. monitor fluctuated from S-tach to SR. “Nurse. the nurse indicates pain was located in the substernal region. performing a focused assessment and documenting the essential information. He or she acts quickly. The nurse also notes on the pain flow sheet: No preceding activity or past history of this type of pain. location. the nurse used quotations around the patient’s words. Documentation of what the patient said: Subjective data 2/15/07 16:00 Patient stated. Second Edition .

O2 could be decreased. • The pulse-oximetry assessments are documented every hour until within normal range. the notations indicated. Based on ABG results. In addition. pain assessments. Second Edition . no decreased level of consciousness. In the cognitive section of the patient care flow sheet. clammy. noting sinus tachycardia. no peripheral edema.. Case Study Documentation of what was done: Intervention The nurse continues to document his or her interventions and the patient’s responses. an increased respiratory rate. morphine sulfate. Patient informed as to the reason for continuous monitoring. gallops. continued on next page Managing Documentation Risk. irregular heart rate. and measures abnormal O2 saturation via pulse oximetry. No changes in mental status.) The nurse assesses lung sounds and the respiratory rate and pattern. ABG’s and EKG.g. In the narrative notes. regular. disorientation. The nurse continues hourly VSs. rubs. etc. including cardiac enzymes. Skin cool. and above-baseline blood pressure for this patient. Frequent monitoring: • The VSs were noted every few minutes until the chest pain subsided. the nurse notes. and signs and symptoms of the patient. murmur. • Fluid intake and output: Recorded every four hours. when he or she is notified. respiratory-assessment findings. Skin assessment also is conducted and documented. the nurse records auscultation of heart sounds (e.Key aspects of documentation 1 Good documentation reflects the nursing process (cont. The patient’s actions are already noted as increasing anxiety. Oxygen therapy: • The nurse documents the patient’s initial pulse-oximetry reading. and every four hours thereafter. • O2 decreased to 2L Continuous cardiac monitoring: 2/15/07 16:03 Patient placed on cardiac monitor. ashen in color. and ABG results. • All treatment activities are documented. There is no clutching of the chest by the patient. SL NTG. No cyanosis noted. or confusion.) The nurse documents the vital signs.

Morphine 2 mg. time of notification. During the remainder of the shift the nurse documents his or her assessments of the IV site and line patency. Subsequent rhythm strips are obtained according to MI protocol (such as change in condition. The patient’s rhythm strip is labeled with the patient’s name and strip intervals. names.) The nurse notes the time the patient was first placed on the cardiac monitor (in MCL1) and the teaching about the reason for the monitor. and QRS-complex duration. catheter gauge. I’ll call you before I do anything. O2 increased to 4 L. The pain flow sheet indicates the patient’s response to the NTG and morphine. New orders received and transcribed. and condition. or arrhythmia). 12 lead EKG done. On the IV section of the patient-care flow sheet. Chest pain unrelieved by NTG. Communication: The nurse is good at documenting his or her communication with other healthcare team members. Smith notified of 2mm ST elevation. The patient does have a ST-segment elevation. Case Study Drug and IV therapy: The Medication Administration Record notes the names. which is noted on the strip. Stat SL NTG. The nurse does document notification of the physician for a significant change from the initial strip. continued on next page Managing Documentation Risk. Also notes the catheter size. dosages. IV PRN given. Second Edition . Activity: 2/15/07 17:30 Patient informed of activity limitations due to change in her cardiac status. the nurse documents his or her assessment of the IV site—the date and time the IV line is inserted. It is found in his or her narrative notes. etc. ectopic beats noted. Each strip has a notation as to the heart rate and rhythm. PR-interval. times. “Don’t worry. The nurse also documents the patient’s vital signs after each dose of nitroglycerin and morphine. Patient stated. He or she also records which lead is being displayed on the strip and the flow sheet.1 Chapter one Good documentation reflects the nursing process (cont. He or she records the physician’s response and his or her actions. and person who does the insertion. and routes of the medications the nurse gives.” The nurse notes the patient is on bed rest and his or her instructions regarding patient-activity limitations. dressing type. 2/15/07 17:02 Dr.

Transfer to ICU: This patient does not need to be transferred. In this case. or thrombolytics • Signs and symptoms of an MI • Signs and symptoms to report • Actions to take when chest pain returns • Medication management (i. Documentation of what was taught The teaching plan needs to be tailored to the patient’s condition and treatment. how well the patient/family understood the teaching. and how to store the medications) • Smoking cessation advice • Diet management • Activity and rest patterns • Community support groups. Second Edition . if applicable. but if she had. the materials used for teaching. prescribed drugs and their names. a written record of the patient’s belongings would have been included. Offered medication to assist in decreasing her anxiety. Patient agreed to medication. etc. • times to take them. attempted to get the patient to talk about her feelings. the method of teaching.. stents.Key aspects of documentation 1 Good documentation reflects the nursing process (cont. nurses discuss the following with this patient: • Heart anatomy and physiology • Disease process • Diagnostic tests and the reason for them • Treatment options such as angioplasty. Documentation of patient/family teaching needs to include what was taught. The nurse also would have recorded the name of the person who accompanied the patient and which monitoring devices were in place during the transport.) Emotional support: 2/15/07 20:10 Patient increasing in anxiety.e. the nurse would have documented the aspects of the patient’s condition that warranted the transfer. The nurse offers and documents emotional support to help the patient cope with the physical and psychological impact of her condition. Someone would have to document how well she tolerated the transfer. route. The report to the ICU nurse would have been documented and. dosages. cardiac rehab centers (Sparks 2001) Case Study Managing Documentation Risk. any potential side effects.

3rd edition. and When Nurses Need to Document.” Journal of Advanced Nursing 53(2): 151-159. 2001. What. K. What. et al. 1999. 2004. Surefire Documentation: How. S. “Discursive practices in the documentation of patient assessments. and C. St. Iowa Outcomes Project Nursing Outcomes Classification (NOC). and When Nurses Need to Document Philadelphia: Mosby. 2nd edition. Taylor.0 Chapter one references Goldberg. Managing Documentation Risk. Sparks. Philadelphia: Mosby. 2006. S. Inc. K. Mosby’s Surefire Documentation: How. PA: Springhouse Corp. et al. Springhouse. Inc. Second Edition . Moorhead. Louis: Mosby. Irving. Nursing Diagnosis Reference Manual. Mosby. 5th edition.