Download Documentation and the Medical Record, Risk Management

ASC Documentation - The
Do’s and Don’ts for Reducing
Risk in the ASC Setting
Dawn Ruiz, R.N., MSN, CPHQ
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Nothing
to
Disclose
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Acknowledgement
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Jeanne Turvey - Lockton
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Objectives
Following this program, the participant will be able to:
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Define “standard of care” and how that relates to the
documentation of patient care.
List five characteristics of appropriate and
inappropriate clinical documentation
Define the elements of negligence and how these
relate to the documentation of patient care.
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Objectives
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Identify documentation requirements unique
and/or high risk to surgical patients.
Understand how proper documentation can
help reduce the risk of litigation.
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Transition of Care
 Since 1991, more surgical procedures performed in
outpatient than inpatient settings.
 Outpatient procedures represent >3/4 of all operations
performed
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2001-2008: >50% increase in number of CMSCertified ASC’s.
2007: >6 million procedures performed in these
facilities and paid for by CMS at a cost of nearly $3
billion.
Higher complexity procedures performed on patients
with greater co-morbidities
Barie, P.S. Infection Control Practices in Ambulatory Surgical Centers, JAMA, :303:2295-2296.
Schaefer MK, et al. Infection Control Assessment of Ambulatory Surgical Centers: JAMA;303:2273-2279.
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Why are we here?
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Experiences
To make a difference
Worthwhile work
Enjoy working/helping
others
To make a change
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“Standard of Care”
Definition:
What a reasonable healthcare professional
does for a patient under the same or similar
circumstances.
o Provide guidelines
o Define appropriate levels of quality care
o Protect the patient
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Sources of Standards
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AAAHC
Joint Commission
State Statues and
Regulations
CMS
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American Nurses
Association
Nursing texts & articles
By-laws and Rules and
Regulations
Policies and
Procedures
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Basic Concept: “Negligence”
The four elements of negligence that must be proven:
1. A duty owed to plaintiff.
2. A breach of duty or standard of care by the
professional.
3. A proximate cause or causal connection between the
breach and the harm or damages
4. Actual harm or damages suffered by the plaintiff
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Nursing Negligence and Malpractice

Foreseeability

Nurse has a responsibility to foresee harm before
it occurs and eliminate risks
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Admission screens
Fall risk
Suicide risk
Illusion of Negligence
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Evidence of the truth as to what really happened
is unavailable
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Nursing Negligence
AJN lawsuit analysis of 250 cases found
six major areas of negligence (2003).
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The six areas of “negligence” include
the following:
1.
2.
3.
4.
5.
6.
Not following the standard of care.
Lack of responsible use of equipment.
Poor communication.
Failure to assess and monitor.
Not advocating on the patient’s behalf.
Failure to document the patient’s progress and
response to treatment, injuries, pertinent assessment
information, physician orders, and telephone
conversations with physicians.
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Failure to Monitor
May be alleged as….
 Not listening to the patient and/or family.
 Lack of attentiveness and surveillance of patient condition.
 Failure to pick up on early signs of complications - event
“rare, but known,” complications.
 Failure to follow through on learned intuition, professional
experience, gut instincts.
 Not including family or patient representative in observations
or concerns about patient.
 Delay in early mobilization of hospital resources.
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“Failure to Rescue”
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….a bedside caregiver’s failure to save---or to
initiate saving---a hospitalized patient’s life or
extremity in the event of a complication….
…and a “failure to rescue” may be one of the
allegations that is involved in litigation against your
facility and/or you.
So….be sure you are documenting your monitoring
and surveillance of the patient’s condition---and
meticulously documenting changes in the condition
and what you did to initiate “rescuing” the patient.
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Case Study
Marsha 27 yo female
1week postpartumGravida 3 Para 3
Presented to ED via
ambulance with vaginal
bleeding since day prior,
dizziness, shortness of
breath, and hypotensive.
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What happened?
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Patient’s physician did not practice at hospital
New OB/GYN doctor on call
Lack of assessment of bleeding
Order for blood but blood transfusion was
delayed
Lack of communication
Went for D&C- ended up with hysterectomy
Went into DIC- died later that day
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What the documentation showed…
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Arrived in ED 0115.
ED nurse documented bleeding one time Marsha was in ED from 0115-0315.
To OR at 0315 - OR nurse did not document
bleeding
Type and Cross for 4 units of blood ordered at
0155 not available until 0500.
Patient stated: “I feel like I am going to die.”
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What the documentation did not show.....
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Frequent assessments
Documentation of intake and output
Description of blood loss
Follow up or status of blood
Consent for blood
Policy for blood triaging
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What was included in affidavit…
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Standard of care - nursing assessment
Standard of care - prevention of complications
Emergency Nurses Association - Assessment,
Implementation, Evaluation
Blood bank - policies for communication for
retrieval of blood
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Linking Monitoring and Rescuing to
Documenting
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Two years from now, will your documentation
reveal what you observed and what you did?
It will if you documented:
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The results of your monitoring of the patient (factual,
specific, complete).
The actions that were taken, including calls to the
physician.
The results of your actions (orders, patient response,
ongoing monitoring, etc).
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Patient Hand-Offs
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High-risk, vulnerable periods of time for
patients related to levels of monitoring,
among other things.
Communicating patient-specific information
from one caregiver to another, ensuring:
o
o
Continuity of care
Safety
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Patient Hand-Offs
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Handoffs can occur:
o
o
o
o
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From one PROVIDER to another.
From one LEVEL of care to another (e.g., ED to
OR).
Temporarily, between areas of care (ED to Blood
Bank).
Discharge to home or other care setting.
Safe handoffs must include an opportunity to ask
questions and share concerns about the patient.
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Patient Hand-Offs
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Important components:
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Name, DOB, other identifiers
Doctor’s name
Diagnosis and current condition, including
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High risk for falls
Allergies
Problems that are active
Stability or potential instability of vital signs, etc.
Recent events/changes in condition or treatment
Anticipated changes in condition or treatment
Time to ask questions and get clarification
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Common charting mistakes
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Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record that medications have been given
Recording on the wrong chart
Failing to document a discontinued medication
Failing to record drug reaction or changes in the
patient’s condition
Transcribing orders improperly or transcribing
improper orders
Writing illegible or incomplete records
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Think Like a Juror….
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Pop Quiz

Poor documentation must be an indication
that the care was also poor. (True?)
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If it was documented, it was done. (True?)
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An Incomplete or Sparse Record
May lead to an (inaccurate) inference that your care was:
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Incomplete,
Sparse,
Lacking or absent, and, therefore,
Not meeting professional standards of care (i.e.,
negligent).
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We Love to Document
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Purpose of Clinical Documentation
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Record and archive the care of the patient.
Communicate with other caregivers taking
care of the patient.
Support reimbursement for the care of the
patient by third-party payor.
Provide evidence of care for regulatory
surveyors.
Medicolegal risk reduction.
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The “Do’s”- Basics of Documentation
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Know the professional and
regulatory requirements for
documenting the care given
in your department.
Know your hospital’s
policies regarding
documentation
Factual
Truthful
Complete
Clear
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Concise
Timely
Continuous
Flowing
Accurate
Correct spelling and
grammar
Legible
“Paint the picture” of what
is happening with your
patient in narrative notes
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Narrative Notes
(in a “Sea” of Flowcharts and Checklists)
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Be sure that all pieces of documentation:
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Describe the patient’s general status and progress
“Paints the picture” of what was happening with
your patient for “readers” who need to know:
 Appearance
 General physical condition
 General demeanor and affect
 Mental state
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The “Don’ts”- Basics of Documentation
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Skimpy or sparse
Ambiguous
Vague
Informal
No slang words
Misspelled
Too “wordy”
Forget to document history,
assessment, and procedures
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Use words that negatively
label the patient, such as
“obnoxious,” “belligerent,”
“hostile,” or “rude”
(Habitually) one long note
at the end of every shift
Nonstandard abbreviations
Copied and pasted over
(and over) (and over) (and
over)
Long after the fact (i.e.,
VERY late entry notes)
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Minimizing Liability
Even though proper care is given, an incomplete
or sparse (bare minimum) medical record may
result in a claim:
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Care was incomplete or sparse.
Care was absent.
Care did not meet professional standards of
practice.
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Minimizing Liability
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Tell the truth
Document care provided
Use appropriate grammar and spelling
Document conversations with other care providers
and family: who, what, when, where
Document interventions before and after notifying
the physician
Document chain of command calls (who, when)
Correct charting errors appropriately (policy)
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Minimizing Liability
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No slang words, phrases, or texting jargon
No personal comments about the patient
No “editorial comments” or blaming, or criticism of
other caregivers
No jokes
No exclamation points (unless directly quoting the
patient or family)
No “white-out” or erasures on any paper document
that is intended to be retained (unlike worksheets)
Most important - NO GAPS or blank spaces
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The “Nevers”
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The “Nevers”- Basic Documentation
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Never alter or destroy a portion of the medical record.
Never “point a finger” at another healthcare professional in
the medial record.
Never chart in advance
Never keep notes in the trunk of your car, locker, clipboard
(or anywhere else) after the shift to use as a personal
reference---if you have something to document, use:
o
o
o
The medical record.
An incident report and send it to Risk Management.
Your supervisor to assist you if you are unsure how/where to
document an unusual occurrence.
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Specialty-Specific Documentation
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Documentation of Surgical Patient Care - “Dos”
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Ensure the H&P and
documentation of the informed
consent are on the chart.
Document required elements of
the Universal Protocol.
Document patient care
MONITORING,
SURVEILLANCE,
VIGILANCE of their condition.
Document assessments,
concerns, communication, and
interventions performed
following unexpected change in
patient condition.
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Documentation of the Surgical Patient Care
- “Dos”
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Document extra-special or
out of the ordinary
interventions (ex., extra
padding, special
positioning, etc.)
Follow documentation
policies related to
implantable device
tracking.
Document chain-ofcommand interventions
appropriately.
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Documentation of Surgical Patient Care “Dos”
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Document interactions with family members
regarding patient status during or following
procedures.
Document reportable adverse events,
including equipment and supply failures
impacting patient care, in both the patient’s
medical record and incident report.
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Documentation of Surgical Patient Care Don’ts
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Don’t take specimen labeling for granted - take extra
care to be sure specimens are labeled correctly.
Mistakes can be irreversible.
Don’t send equipment for repair or service without
adequate documentation of the problem(s).
Don’t assume someone else will document adverse
patient care events. (They won’t).
Don’t leave gaps or blank spaces in flowcharts or
checklists.
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Documenting “Difficult”
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Difficult Patients or Families
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Medically frustrating
Noncompliant
Behavior or personality issues, such as
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Demanding
Complaining
Whining
Seductive
Needy
Belligerent
Rude
Hostile
Combative
Violent
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Addressing and Documenting These
Situations
1.
Try to understand WHY they may be acting
this way:
a.
b.
c.
d.
e.
This is how they are coping
Feeling mistreated or ignored
Social or financial problems
Lack of trust, information, or communication
Cultural divergence
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Addressing and Documenting These
Situations
2.
Recognize their effect on you:
a.
b.
c.
3.
Interfere with your confidence in your own skills
Psychologically draining
“Compassion fatigue”
DOCUMENTING difficult patient and
families:
a.
b.
Factually-describe the Behavior
Be careful using LABELS
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Documenting Difficult Patients and
Families
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Avoid using these labels:
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Demanding
Complaining
Whining
Seductive
Needy
Belligerent
Rude
Hostile
Combative
Violent
………and document factually what is said, the observed behavior, etc.
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Adverse or Unusual Event Documentation
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Adverse or Unusual Event Documentation
The same “rules” apply:
 Factual
 Truthful
 Complete
 Clear
 Concise
 Timely
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Correct spelling and
grammar.
“Paint the picture” of what
was happening with your
patient in narrative notes.
Avoid skimpy, vague,
ambiguous, and very late
entries.
These “rules” apply to both
incident reports and
medical records.
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Important to Remember

When things are going badly….that is when you (or
your staff) have the least time to document and the
most need to do so impeccably and without fail.
Know when to say, “this is one of those times.”
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Documentation is your (most boring, time
consuming) best friend when you have had a patient
emergency or adverse event.
Documentation will help protect the hospital’s
reimbursement.
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Good documentation is a skill that is
learned with practice!
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Questions?
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References
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Aiken, T.D. and Catalano, J.T., (1993). Legal,
Ethical, and Political Issues in Nursing 7-1.
Campos, N.K., The legalities of nursing
documentation, Men in Nursing Vol. 40 Number 1,
7-9.(accessed July 9, 2011).
Sandra K. Johnson, Documentation and the Medical
Record, Risk Management Handbook for Health
Care Organizations 265,271-275, 278-279 (Roberta
Carroll ed., 4th ed., Jossey-Bass 2004).
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References
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
Sandra K. Johnson, Documentation and the Medical
Record, Risk Management Handbook for Health
Care Organizations 265,271-275, 278-279 (Roberta
Carroll ed., 4th ed., Jossey-Bass 2004).
Leacock-Ballish, P., and Spader, C. Preventing
Documentation Errors,
http://include.nurse.com/apps/pbcs.dll/article?AID=2
005504250347 (accessed July 9, 2011).
Peterson, K.F, and Zimmerman, G., Nursing
Negligence, http:www.rkmc.com/NursingNegligence.htm,(accessed July 9, 2011).
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References
Dawn Ruiz, R.N.
Senior Director- Clinical Operations
National Surgical Hospitals
Phone: 704-843-5285
E-mail: [email protected]
Every effort has been made to ensure the accuracy of the information
provided in this presentation. Only sources were used that were believed
to be credible, accurate and reliable. However, no guarantee or
warranty with regard to the information provided is made or implied.
The information contained in this presentation is not intended to be
medical or legal advice.
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