Administration & Leadership – Medical Documentation
After completing the course, the learner will be able to:
- Identify at least one Joint Commission documentation guideline
- Discuss The Joint Commission’s “do not use” abbreviation list
- Describe two different documentation formats
- Discuss the limits of copying and pasting in an electronic health record.
- Apply strategies to avoid legal problems with documentation
We live in a culture of measurement. Actions, observations, and intent are all subject to review and comparison toward desired standards. In order to meet pressures internal to our profession as well as those which exist externally, records must be generated, stored, and maintained. Medical documentation has become a component of health care as significant as the rendering of hands on, direct person interventions. Refreshing our knowledge of documentation premise and process is essential to hone our professional technical skills.
The Health Record
Medical documentation refers to any written or electronically generated information about a client which describes services or care provided. Documentation may be in the form of paper records or electronic documents. Electronic documents include computer created medical record files, faxes, e-mails, texts, pictures, video or audio recordings. Through documentation, key observations, decisions, actions, and outcomes can be communicated, as well as preserved in a lasting fashion. The intent of documentation is the creation of a lasting accurate accounting of what occurred and when it occurred.
The challenge today is to provide succinct, yet comprehensive records that accurately portray the client’s experience while meeting the standards of professional and organizational care, regulatory requirements, fiscal responsibility, and criteria for reimbursement. This record of care is a legal document and includes information from nurses and various other health professionals who have contributed to client outcome.
With the abundance of information sources present in health care’s data rich environment, a definition of exactly what elements comprise the legal health record is important. Guidelines from AHIMA, the American Health Information Management Association, suggest that each organization be responsible to define the content of the legal health record in accordance with its system capabilities and the legal environment, well before a legal or regulatory issue arises. (Butler, 2013).
Each health care facility must have a compliance system able to guide and ensure accurate and complete record generation (e.g. documentation), record maintenance, and records destruction (when appropriate). AHIMA, AHCA (the American Health Care Association) and other organizations offer guidance to facilities to help them comply.
Compliance is a timely issue, and not only for acute care. Section 6102 of the Affordable Care Act requires NF (nursing care facilities providing long-term care, generally under Medicaid) and SNF (skilled nursing facilities providing rehabilitation care, generally under Medicare) to possess compliance and ethics programs geared toward preventing, detecting, and reporting violations of federal or state laws, regulations, as well as any indications of fraud or abuse.
Each facility rendering nursing care should have a system in place which addresses the following:
- Storage and maintenance of records and information in a safe, secure place
- Routine creation and maintenance of copies of electronic documentation
- Limiting access to records in order to prevent fabrication or destruction
- Development of document retention and destruction policies that are consistent with applicable laws, regulations, and policy
Legal health records must meet accepted standards present within each organization as well as those applied by review or oversight authorities such as the Centers for Medicare and Medicaid Services (CMS), state and federal regulations, or The Joint Commission on Accreditation of Healthcare Organizations (TJC).
While organizations such as CMS and the Joint Commission recognize that both physical (e.g., paper charts) and electronic health records must be individualized to the unique needs and settings of that care facility, some basic components should uniformly be present:
- Client identifying data
- Name, birth date, residence, sex, blood type, etc.
- Known medical history
- Medical, surgical, medication, family history, social, immunizations, etc.
- Medical encounters
- Summations of interviews, assessments, and interventions by medical personnel such as physicians, specialists, consultants
- Orders and Prescriptions
- Medical orders for specific treatments or medications
- Progress notes
- Documentation – in chronological order – of observations or care given by all members of the health care team that have led to the client’s current state of health
- Test results
- Laboratory reports, imaging studies, pathology results, respiratory testing, etc.
- Other information
- Such items as flow sheets (i.e., Intake and Output, Vital Signs, etc.), Medication Administration records, ECG tracings, informed consent documents, educational needs assessments, etc.
A good example of the emphasis on detail expected comes in the form of the Joint Commission standard on medical documentation, expanded so that the individual elements of performance (EP) can be seen.
In the April 2014 Joint Commission Resources live telecast on challenging medical record and infection control standards, the panel of Joint Commission expert surveyors point out some of the following key points and issues they observe during their nationwide surveys of hospital and healthcare facilities (JCRQSN, 2014):
- The health record should read like a novel with a beginning (admission), middle (active treatment to better the client), and an end (discharge or transfer).
- When it isn’t clear in the record why care is being given, the result of what the care given is, or even if there is any care given at all then there are definite issues affecting payment for care and organizational accreditation.
- Meeting the record of care elements of performance is a continuing challenge. It is important to know what they are, and make sure they are met.
- Staff forgetting or neglecting to date and time documentation entries is one of the top reasons for health organizations being cited.
Evidence Base of Documentation
Excellent health record documentation is evidence based care. Nursing documentation is the subject of frequent study and analysis. The findings of one recent meta-analysis disclosed the following essential points concerning quality nursing documentation (Scruth, 2014):
- Quality nursing documentation is written to reflect the objective clinical judgment of the nurse, what they hear, see, or have expressed to them directly from the client.
- Quality nursing documentation must be client centered, the client’s perceptions just as reported to the nurse along with the nurses’ response or interventions.
- Quality nursing documentation contains the actual work done by the nurse such as education, physical intervention, or psychosocial support.
- Quality nursing documentation must be presented in a sequential, logical manner.
- Quality nursing documentation must be time sensitive, with the documentation point immediately following the time of an event or soon afterwards.
- Quality nursing documentation must satisfy legal requirements providing a comprehensive description of the client’s experience, demonstrating that the nurse understands the client’s diagnosis and condition with interventions to manage any issues arising on their watch that have the potential to effect the client’s outcome.
Just in case you were thinking the study and analysis of documentation a boring, if important topic, findings from documentation styles and trends can be literally, lifesaving.
Communication of Information
Documentation in the client chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observe as well as how we respond with interventions, or by forming plans of care, must be entered into the chart.
Health care facilities are tasked by organizations such as the Joint Commission or the Centers for Medicare and Medicaid Services to effectively manage the collection of health information using uniform data sets and policies which guide record creation and handling. While the components of the health record may differ somewhat in each facility, certain standards are expected for both paper and electronic documentation systems.
Suggestions from external sources can be very specific, such as the July 2014 posting from the Joint Commission concerning updates to the abbreviation use standard first implemented in 2001 as a Sentinel Event Alert. The abbreviation standard with its “Do Not Use” list of banned abbreviations is currently codified as TJC Information Management (IM) standards of performance elements 2 and 3 under IM.02.02.01. In this standard each hospital is required to have a written policy that addresses the use of abbreviations and symbols. This policy is to address all orders and medication related documentation that are handwritten (including free-text computer entry) or on pre-printed forms.
Communicating Clearly in Chart Notes
The knowledge base offered within the profession of nursing is full of practical information. Common practice experience leads to acceptable ways of handling information clearly and consistently.
Progress notes are essential medical records based on the nursing process: assessment, nursing diagnosis, planning with goal setting, implementation/ interventions, and evaluation. Progress notes serve to;
- Establish a communicated baseline
- Record relevant data at regular intervals
- Provide snap-shot summaries of a client’s condition
- Document changes in condition
- Document response, or lack of response, to treatment
Each care setting tends to specify the patient data format or chart note style that they prefer for progress notes. Follow your facility’s documentation policies. There are many charting styles currently available. Each notation format has advantages as well as disadvantages. Some have been around for a long time while others are rather new. Many institutions blend format systems together to get the record-keeping style that works for their unique needs. Whichever style is used, communicate clearly to avoid potential legal problems. Careful forethought and practice using a charting strategy will lead to consistently clear and legally defensible documentation.
The narrative note is the most traditional medical record progress note style. It involves the documentation of assessment data, interventions made and patient responses in chronological order with free flowing structure, content and form. Many facilities rely solely on this format, while in other settings narrative notes serve to supplement check-off forms and flow sheets.
Narrative charting tends to be thorough and detailed. It is also time consuming. The narrative chronological format is popular with nurses who document complex descriptions with comprehensive assessments.
One key legal issue with this style is that shift to shift, person to person, inconsistency makes it difficult to follow the patient’s progress and plan appropriate care. Each nurse may write her notes with a unique style, thus making continuity of care more difficult. Since this form allows for “free-flowing” paragraphs there is more room for sloppy writing, spelling errors, rambling repetitive narration, inappropriate personal opinions, and inaccurate language. Although these problems are not necessarily indicative of negligence, a negative inference may be made regarding the “professionalism” of the nurse and the facility.
To avoid problems, make certain that each nurse tries to achieve a measure of consistency with record keeping. Perhaps decisions can be made regarding the placement of vital signs, patient outcomes, and care rendered within each narrative paragraph. Have a dictionary available to help with spelling problems. Handwriting must be legible and descriptions of patient observations must be precise. When flow charts are used to document vital signs, avoid repeating that information in the narrative unless there is a specific change that you are addressing in the note.
Problem Oriented Medical Records
Problem area charting focuses on specific needs rather than general assessment information. POMR or problem oriented medical record systems frequently use acronyms to provide memory aides as to the structure of the progress note being written. As POMR documentation focuses on specific problems; it is sometimes generically referred to as “focus charting”.
Some problem oriented charting acronyms:
- SOAP – Subjective, Objective, Assessment, Plan
- SOAPIER – Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
- APIE – Assessment, Plan, Intervention, Evaluation
- DAPE – Data, Assessment, Plan, Evaluation
- DARE – Data, Assessment, Response, Education
- DARP – Data, Assessment or Action, Response, Plan
We will now look at examples of POMR format charting as they move along a continuum away from straight narrative documentation.
SOAP – SOAP charting follows a distinct format that defines the various sources of information followed by a plan of intervention. SOAP stands for subjective, objective, assessment, and plan.
- Subjective provides the client’s condition in a narrative form using that person’s own words to describe their condition and concerns
- Objective relates findings such as vital signs, observations from physical examination, laboratory results, measurements (i.e., weight, age, etc.)
- Assessment summarizes findings into a professional observation of the patient’s condition such as is found within the nursing diagnosis system
- Plan details what the nurse will do to address the client’s needs
SOAPIER – The basic SOAP format for progress notes are sometimes expanded to fit unique organizational needs, such as;
- Intervention that details specifics of the Plan formulated in the earlier SOAP system
- Evaluation of outcomes from the nursing care plan
- Revision of planned care needed, based on the evaluation that occurred following the intervention
DARP – DARP moves further along the continuum away from straight narrative-chronological charting into a combination of check-off forms and flow sheets supplemented with narrative progress notes. The POMR style progress note usually follows the DARP format;
- Data gathered is related to a focus issue (e.g., a summary referring to information found on a checklist or flow sheet)
- Assessment of the data with additional information not related by the flow sheet (NOTE: Action is sometimes substituted for, or integrated into the Assessment phase)
- Response to the need brought into focus during the assessment of available data
- Plan for continuing care following the intervention phase of the response (i.e., continuation of observation, education of client, notification of another professional, etc.)
Risk management strategies with this charting style need to make certain that nurses from the unit where the forms will be utilized have input into design of the check-off forms and flow sheets. Ample room must be present to record pertinent information. Each institution should provide the staff with sufficient training to utilize the strengths of this system to its best advantage.
Charting by Exception
Many consider charting by exception (CBE) the antithesis to narrative progress notes. CBE is a format developed to overcome the recurring frustration of sometimes lengthy, repetitive narratives. It consists of a heavy component of flow sheet documentation with a blending of POMR narrative added. Quickly marked checklists and flow sheets document normal assessment findings and routine care. Any narrative documentation done is limited to findings outside the expected norm.
One strong advantage is that flow sheet design can incorporate clearly defined expectations for the type of patients cared for on each unit and in each care setting. A standardization of forms process within each facility allows caregivers to provide consistency in patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by nursing interventions. Charting by exception can reduce the amount of time spent on documentation.
Charting by exception has the potential to be a great asset to electronic medical records documentation. The use of quickly scored checklists that document routine matters complement at-the-bedside computerized data entry. By shifting the emphasis from descriptive, discursive narrative paragraphs for every routine and expected event, CBE uses minimal narrative notes for only unexpected or highly significant events. CBE may be the cutting edge of medical documentation, or a significant pitfall if you do not know how your organization delineates the all-important WDL “within defined limits”. (Morales, K., (2014).
Since charting by exception is a departure from more traditional medical documentation models, it can lead to legal challenge. The biggest problem noted seems to be the appearance of large gaps of time without patient contact. Although this is not true, if no significant observations are made, no notes will appear in the record to prove the nurse’s attentiveness. Likewise, wellness promotion and preventive care may not be a component on a patient problem checklist, preventing full credit for the work done.
Clinical pathways (aka care pathways, critical pathways, care maps, or integrated care pathways) are multidisciplinary descriptions of the expected care for a specific illness or condition with a specified timeline for the anticipated length of stay. Pathway focus is on outcomes and efficient use of resources while still providing quality care. Pathways have proven to be a good way to identify variances from expected outcomes and promote efficiently organized care that is centered on evidence-based practice.
Typically, pathways are written to address a specific condition. It usually includes the expected length of stay, care setting, timeline, assessment, multidisciplinary interventions, patient activity, medications, lab testing, patient and family education, and outcomes. Some facilities are using clinical pathways in conjunction with charting by exception. Use of pathways is changing documentation in many healthcare settings. Managed care, for example, is heavily invested in clinical pathways, recognizing them as an important tool for rendering and documenting quality care.
The major focus for avoiding the legal complications in clinical pathways is the understanding of how your facility is using them and what supportive documentation is required. At some facilities, the pathway has replaced the traditional care plan and progress notes with documentation made directly onto the pathway document unless the patient does not meet the outcome. At this point, a narrative note is made.
Electronic Health Records
Software programs are available to capture patient data in a computerized format. Depending upon the system selected by the facility, information may be entered by keyboard, voice activation, mouse, touch-sensitive screen, or a combination of these methods. Some systems allow the nurse to select pre-written phrases to describe the patient’s condition with very little sentence formation performed by the nurse.
Ample education must be provided before implementing a computerized system. A “hard copy” of essential information should be printed at designated times to ensure an accurate record in case of computer problems. Error correction must be completed before the information is permanently stored, and all information should be double-checked before you enter it. Any corrections made after storage will have to be specially noted using the tools and processes specific to EHR your system.
Remember the basics of HIPAA training related to the use of electronic health record documentation.
- Never leave a computer terminal unattended after you have logged in
- Do not leave information about a patient on the screen when others can view the monitor
- Never give your personal password or computer signature to anyone
- Tell a supervisor if you suspect someone may have used your code.
Legally Defensible Charting
Certain guidelines apply regardless of the documentation format you use. The following tips will help ensure that your record keeping can be defended in the courtroom.
Legibility is essential. Never second-guess someone else’s writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial, not only for safe patient care, but also because they enhance your professionalism. Make sure a dictionary is kept at the nurses’ station and post a list of commonly misspelled words. Avoid abbreviations completely when possible. If you must use them, use only abbreviations approved by your facility.
Make sure you have the CORRECT CHART, for the CORRECT CLIENT before you begin writing.
The medical record is a permanent legal “business record” and as such, entries must not be made in pencil or erasable ink. Write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest clarity. If you use a highlighter in your record, perhaps as a way of noting discontinued medication, make certain that your medical records department can effectively copy highlighted information. Some copy machines “gray out” any writing covered by highlighter.
If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.) use double-sided tape or tape only onto blank paper. Even though the tape itself is clear and can be read through by the naked eye, a copy machine may “black out” the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copy machine fax, the ink on the fax may be water-soluble and fade in a matter of days.
EVERY PAGE of the record must have the date and patient name. This is required for a record to be admitted in a courtroom setting.
Your complete signature is required once per page. Your complete signature is your name followed by your professional designation.
When adding a progress note, follow institutional policy to determine if you are to note the time that the entry is being added, rather than the time that the observation took place.
Avoid block charting, such as “11:00 p.m. to 7:00 a.m.” This type of documentation gives the impression of vagueness. Note exact times of all critical treatments, physician contact, or notices to supervisors. Any time you leave a message with someone in a physician’s office, note the time and the name or title of the person taking the message.
Make certain the “proper” person does the documentation. For example, The Joint Commission requires that the initial assessment and care plan be performed and documented by a registered nurse. Documentation by the proper person is especially important in educational, nutritional, and rehabilitation assessments.
Avoid documentation practices that either allow or allude to alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise when you have completed your thought, draw a line through any remaining blank space on the line before signing your name. Do not leave blank lines between entries.
Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care.
To correct written entries, put a single line through the error then add your initials and the date of correction. You may note “error” or “mistaken entry.” Do not use white out or tape designed to obliterate typographical errors. Do not correct another’s error. Likewise, if you do not agree with an entry, do not record your opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best possible care and the chart reflects respect for all health care team members.
When possible, chart as soon as you can after you make an observation or provide care. This helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made on a following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding (Small, D., & Rutherford, L., 2009):
- Add the entry to the first available line,
- Indicate clearly “Late entry,”
- Record the day and time you are writing the entry, and
- In the body of the paragraph, indicate the day and time of the previous event now being described.
Never chart for someone else. If you did not participate in an activity or observe someone else’s care do not write anything. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:
“At 8:35 a.m., Nurse Joann Green called and reported that at 5:30 a.m. this morning she observed…”
Understand countersigning. Only countersign notes when required by the institution.
- If you merely review someone’s note, co-sign in the following manner:
- ?“Student Nurse name/Entry Reviewed by Jane Doe R.N.”
- If you actually participate in the activity, co-sign in the following manner:
- “Student Nurse name/Jane Doe R.N.”
Keep documentation objective. Do not chart opinions or assumptions. Rather than writing “the patient was unresponsive”, your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid phrases like “perhaps”, “maybe”, or “I think”.
Be careful to avoid labeling the client. For example, avoid descriptive terms like “demanding”, “drug seeking”, “abusive”, “lazy”, “drunk”, “mean”, “litigious”, or “out-of-control”. Instead, note observations as a description of the behaviors.
Unusual occurrences and patient injuries need documented. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Use quotation marks when documenting comments from the patient, roommate, or visitors. Record the patient’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and details of treatment. However, do not mention in the client’s record that an incident report or occurrence report was filled out.
Always document a client’s uncooperative behavior. For example;
- Leaving against medical advice,
- Refusing or abusing medications,
- Failing to follow diet or exercise plan,
- Refusing to follow instructions to stay in bed or ask for assistance,
- Failing to give information that effects care such as complete history, current medication, treatments,
- Patient or family tampering with traction, IV’s, monitors,
- Failing to follow-up with visits to clinic or physician,
- Bringing unauthorized items into the facility
Document any safeguards or other preventive measures you are taking to protect your client (e.g., night light left on, call light available, floor clear of trip hazards, etc.).
Chart that the facility’s safekeeping for valuable possessions system was explained and made available to the client. Encourage the client or family members to send any possessions home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in the safe are recorded on a receipt complete with the client’s name and ID number. Describe each item in detail using objective language. For example, yellow ring with clear stone instead of charting a gold diamond ring. Update valuables list frequently for long-term clients. Before a client is transferred, take an inventory of the valuables list to verify location of items.
Document medication administration as thoroughly as possible. Note the date, time, your initials, the method of administration, and the site where the medication was given if it is an injection. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions. At least once a shift, note the condition of the IV site along with the type and size of catheter.
If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. When omitting a medication, document the rationale. For example, “pain medication held pending stabilization of vital signs”. If a medication order is being questioned, tactfully document your conversation with the physician. If someone is giving your client medication while you are off the unit, make sure that person charts that they administered the medication.
Avoid verbal and telephone orders whenever possible because of the high risk of errors. However, since it is not always possible, the proper method for documentation of verbal or telephone orders includes:
- Time and date of phone call,
- Write the order verbatim, and then read the order back to the physician,
- Document T.O./R.B. (telephone order/read back) or V.O./R.B. (verbal order/read back) followed by the physician’s name and your name
Discharge documentation should include information about instructions given to the client and family related to: diet, activity, medications (name, reason for taking, dosage, and frequency), skin care hygiene, specific treatments, follow-up appointments, and any agency referrals. Along with the note relating that instructions were given, document the client and the family’s comprehension of the discharge instructions. If any skills were demonstrated, record the patient’s ability to return demonstrate what was taught.
The primary purpose of medical documentation is to establish that individual’s health status and need for care, record the care given, and demonstrate the results of the care. Medical documentation allows for the exchange of information between all members of the healthcare team. The health record provides legal proof of the type of care the client received and that person’s response to that care. Medical documentation that is poorly maintained, incomplete, inaccurate, illegible, or altered, generates doubt regarding the treatment given to the client. Be factual when documenting. Do not guess, generalize, or give personal opinions. Rely on your professionally guided physical observations. What did you see, feel, hear or smell? Documentation of client care holds the healthcare team members to professional accountability and demonstrates the quality care you have given.