Documentation & Liability

1. Documentation & Liability Presented by Sue Burnham, RNC, CLNC, IBCLC Evergreen Hospital Medical Center Family Maternity Center

2. Objectives: • Name three (3) purposes of a medical record • Define Standard of Care • Identify the “4 D’s” of Nursing and Medical Negligence • List five (5) ways to prevent nursing malpractice • Identify the chain of command at EHMC

3. The Medical Record • Dictionary definition of a medical record: • “Case history of a patient” • Remember: Content of the record varies by practice setting • Requirementsare set by regulatory agencies.

4. Legal Definition of a Medical Record • According to AHIMA: • The medical record does many things: • Provides a view of a patient’s health history • Clinical communication tool between health care providers • Provides supportive documentation for reimbursement purposes • Documents clinical care and gives key source of data and outcomes research • Major resource for education of providers • Documentation of quality of patient care • Legal business record for healthcare institutions

5. Medical record documentation is an essential link between PROVISIONof care and EVALUATIONof care given.

6. Principles and Guidelines common to all Medical Records • Records are actively used by health care professionals during provision of patient care • Contents vary according to the setting • Regulatory agencies determine items to be included in charting.

7. “If it isn’t charted, it wasn’t done.” • “A chart is the witness that never dies and never lies” (Chagnon, Easterwood 1986)

8. Basic Legal Definitions: • Civil—Criminal • Civil standard of proof • Plaintiff—Defense • Phases of a Civil Trial • Complaint filed • Discovery • Settlement/Trial • Use of RN Experts • Standard of Care

9. Standard of Care • Standard of Care refers to the ordinary skill and care that a reasonable and prudent person would give under similar circumstances. • Standard of Caredoes not require extraordinary skill or care. • Standard of Care requires use of the nursing process. • Standard of Care is defined by the Washington State Nurse Practice Act using the “reasonable and prudent person” standard.

10. Nursing Malpractice:The “4-Ds” of Nursing Malpractice • DUTY • DERELICTION OR NEGLECT OF DUTY • DIRECT OR PROXIMATE CAUSE • DAMAGES

11. DUTY • Professional responsibility that RN has to care for client • Uses the “reasonable person” standard

12. DERELICTION OR NEGLECT OF DUTY • Failure to act as a reasonable or prudent person within the same community would act in the same circumstance • Plaintiff would have to prove that care did not comply with acceptable SOC

13. DIRECT OR PROXIMATE CAUSE • Must be a continuous sequence of events unbrokenby an intervening cause, that produces an injury and without whichthe injury would not have occurred • Plaintiff must prove that RN dereliction of duty was the cause of the injury.

14. DAMAGES • Refers to injuries caused by the defendant. • Plaintiff seeks recovery($) for damages: • Permanent physical disability • Permanent mental disability • Loss of enjoyment of life • Past and future loss of earnings • Medical and hospital expenses • Pain and suffering

15. How can I prevent this from happening? • Documentation is key – • Adherence to unit and hospital policies and procedures • Professional communications skills

16. DOCUMENTATION • Remember the “essential link” between provision and evaluation of care? • Utilize the Nursing Process to plan, provide and document care given to a client— • NP is a systematic method of planning and providing care to clients • Steps of the nursing process build on each other

17. The Nursing Process: • Assessment • Diagnosis • Planning and Outcome Identification • Implementation • Evaluation • Remember: • Steps are not linear. • Work on another step may begin before preceding step is completed.

18. Health care documentation is our professional responsibility—we are accountable for our documentation –which reflects care given

19. Accountability: • Documentation provides written evidence of nursing’s accountability to: • Client • Facility • Profession • Society

20. Critical Elements in Charting: • Accurate, complete and objective documentation • Note date and time • Use the correct form • Identify the client • Use ink • Use standard abbreviations • Spell correctly • Legibility • Errors corrected properly • Sign each entry

21. Always document: • Sudden changes in client condition, significant events, and nursing actions taken • Nursing assessment, evaluation, and documentation MAY contrast with physician documentation • Report of serious symptoms, significant events, changes in condition to physician; Documentation by nursing demonstrates that nursing has fulfilled professional obligation to communicate with the health care team

22. Accuracy and Objectivity • Record facts • Reflect the nursing process in documentation • Document promptly

23. What if the provider does not give the expected response? • Use objectivity in charting – do not subjectively criticize the provider in the chart • Nursing is “obligated to pursue the matter up the chain of command” if the situation demands (NURSING DOCUMENTATION, Iyer and Camp, 1999) • Precision in documentation cannot be over estimated

24. Chain of Command: • See handout • Use your critical thinking skills • First resource: charge RN

25. Preventative Measures to Decrease Liability Risks: • Accurate Data • Written evidence of things done, response of client, revisions to plan of care • Evidence of compliance with professional practice standards and accreditation criteria • Written legal record to protect the client, facility and health providers

26. Summary • Clarity • Concise • Accuracy • Reflect the nursing process • Follow policies and procedures • Our goal is client safety