Transcript Legal Issues and Documentation

Legal Issues and Documentation
Author: Evelyn M. Hickson, RN, MSN, CNS, WCC
Objectives
By the end of the presentation the participant
will be able to:
1.
Discuss the legal implications associated with
working in the Perinatal area
2.
Define the following terms: standard of care,
accountability, negligence, malpractice and
failure to act
3.
Discuss the importance of clear, concise
documentation
4.
State the component parts to and charting
Perinatal Issues
More than one patient at a time –
mother and baby / babies
Multiple areas of care – triage,
antepartum, intrapartum, postpartum,
OR, recovery room
Public expectations of the “perfect birth
and baby”
Trends in Malpractice
Obstetrics one of the areas
with the highest medical
malpractice risk
Statute of limitations for the
child in OB is 18 – 21 years in
most states of the U.S.
Damaged infants are eligible
for a malpractice settlement
that will assist with caring for
them for the rest of their lives
Trends in Malpractice
Increase in the number of malpractice
suits where more non-physicians are
sole defendants in lawsuits
Erosion of the MD as the “Captain of
the Ship”
Lawyers are actually taught how to
sue medical professionals
Direct Nurse Liability
Nurses (LPNs and RNs) are considered
licensed personnel that are trained and
deemed competent – thereby are
accountable for their actions
Direct Manager Liability
Increased numbers of charge
nurses and nurse managers
involved in litigations as
witnesses and co-defendants
Each manager is accountable
for the outcomes of care at his
or her level of authority in the
institution
Vicarious Liability
Hospital or employer is accountable for
acts of the employee within the context
of their job description
Nursing Competency
Based on:
Performance
 Training
 Experience
 Standards of Care
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Standard of Care
What a reasonable and prudent nurse
given similar experience and training
would do under the same circumstance
Standards of Care
More than 20,000 published standards
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National Practice Standards (COBRA/EMTALA)
National Practice Guidelines (ACOG, AAP, CDC,
NIH, AHA, etc.)
Institutional Policies, Procedures, Practice
Standards and Guidelines
Community Standards
JCAHO
International Practice Standards
Board of Registered Nursing / Department of
Health
Professional Organizations (AWHONN, ACOG)
Affirmative Duty
Nurse responsibility to:
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Do No Harm
PREVENT HARM
Requires that we independently evaluate MD/provider
orders, plan of care, treatments and procedures for
appropriateness
Nurse responsibility to determine if the orders are NOT in
the best interest of the patient then required to :
 Question
 Clarify
 Challenge
 Change
 Implement the chain of command to facilitate process
Physician Code of Ethics
American Medical Association Code of Ethics
“Where orders appear to the nurse to be in error or
contrary to customary medical and nursing practice,
the physician has an ethical obligation to hear the
nurse’s concerns and explain those orders to the
nurses involved.
In emergencies, when prompt action is necessary and
the physician is not immediately available, a nurse
may be justified in acting contrary to the
physician’s standing orders for the safety of the
patient.”
Affirmative Duty Documentation
WHO you have notified by name and
title
WHAT you have told them – specific,
factual and true
WHAT you are asking for – specific,
clear
WHAT was the response to your
request
Charting Example
“Drop in FHR to 90s. Pt complains of
increased abdominal pain, MD notified”
“Repetitive variable decelerations to 90 bpm
for 1-2 minutes with slow return to baseline.
Pt turned to right lateral, pitocin turned off, IV
fluid bolus, 02 on at 10 L per non-rebreathing
mask. Cervical exam 4 cm/ 75%/-1 Dr. Smith
notified and requested to come to unit to
review strip and assess patient, states he is
on his way and will be on the unit within 20
minutes.”
Chain of Command
Nurses are responsible for knowing the chain
of command at their place of employment and
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When to implement
How to access all levels
How long to wait before going up to next level
Identify what is the line of authority for:
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Nursing
Medical
Administrative
Liability
“ The provision of substandard care that
results in patient injury”
May & Mahlmeister, 1994
Professional Liability
“Responsibility for acts of negligence”
May & Mahlmeister, 1994
Act of Commission
“Doing something incorrectly or outside
the accepted standards of care.”
May & Mahlmeister, 1994
Act of Omission
“Failure to do something that should
have been done”
May & Mahlmeister, 1994
Routes of Reporting
Quality Assurance / Unusual
Occurrence forms / Incident Reports
Internal Continuous Quality Improvement
Process
 Protected
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Formal memos
Written or phone memos to state
agencies (Whistle Blowing)
Reporting
Mandates – abuse, criminal acts
Negligence
Malpractice
Diversion of narcotics
Do not refer to QA or Unusual Occurrence,
memos in the chart
Do not refer to any protected QA review
process in the chart
The only information that should appear in
the chart are the facts of the situation
Professional Accountability
Definition:
Responsibility for outcomes of care
Professional Accountability
Nurse must be able to:
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Identify areas of limitations, skills
and expertise
Request appropriate training and
orientation to new skills, tasks,
equipment, and roles
Performs nursing functions that she / he
is deemed competent and safe to
perform by education, experience,
training and current expertise
Have knowledge of the law and
standards of care
How to Maintain Professional
Accountability
 Stay
current in practice
 Join
professional organizations
 Attend
conferences
 Participate
as leader within unit
Scope of Practice
Set by State(s) practiced in, national and
institution standards (practice grid)
Orientation
Competency tools
Performance Appraisals
Nurse Practice Act – set by state: nurses
“help people cope with difficulties in daily living
which are associated with actual or potential
health or illness problems or treatment thereof
which requires a substantial amount of
scientific knowledge or technical skill”
Negligence
Failure to have the knowledge and the
skill to perform a duty that any other
prudent nurse would given the same or
similar circumstances.
 The Commission of an act
 The Omission of a duty
Negligent Supervision
Negligence on the part of any nurse
who has supervisory responsibility for
new staff, staff who are floating, LPNs,
Aides, etc…
Also is applied to any nurse who
continues to delegate or assign duties
to another nurse, aide, etc… that have
known deficits or who lack competency
for that task.
Gross Negligence
“An extreme departure from the
standard of care that would have been
practiced by a competent registered
nurse in similar circumstances.”
Barter & Furmidge, 1994
*Applies
to any licensed professional
Most Common Allegations of
Negligence
Failure to assess and
monitor the patient:
As frequently as required by the
patient’s condition or policy or
guidelines
 In accordance with provider
order
 In compliance with the standard
of care
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Most Common Allegations of
Negligence
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Failure to communicate and
report
In a timely manner
Persistently if patient condition
warrants
Implementing the chain of
command
Documenting critical data and
reports
Most Common Allegations of
Negligence
Failure to ensure patient
safety
 Failure to evaluate for risk for
falls – physiologic, neurological,
psychological, etc…
 Failure to provide safety
devices for patient (for
example: side rails, call light)
Most Common Allegations of
Negligence
Medication Errors
 Failure to follow 5 rights
 Failure to check the labels
Most Common Allegations of
Negligence
Failure to follow institutional policy,
procedures and guidelines
Negligent telephone triage and advice
Violation of HIPAA – patient
confidentiality
Inappropriate delegation and/or
supervision
Malpractice
“…refers to the negligent acts
committed by a person in his or her
professional capacity. It is professional
misconduct, unreasonable lack of skill in
professional duties, evil practice or
illegal or immoral conduct.”
Roland & Roland, 1989
Most Common Allegations of
Malpractice
Patient falls – with or without the side rails up
Failure to monitor the patient – undetected changes /
deterioration in condition
Failure to communicate and report changes
in a patient’s condition in a timely manner and
to not be persistent in requesting medical
intervention
Failure to clarify questionable orders or
treatments
Medication errors
Most Common Allegations of
Malpractice
Inadequate discharge planning and
inappropriate or premature discharge of a
patient
Not identifying patient safety risks
Injury due to improper use of equipment
Failure to perform treatment properly
Duties Specific to the RN
Perform Complex Assessments on
UNSTABLE patients
Comprehensive admission assessment
 Reassessment after invasive procedures
 Verification/validation of abnormal
assessment data
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Duties Specific to the RN
Uses nursing judgment to
interpret patient data
Forms opinions and reaches
conclusions by analyzing data
 Determines the meaning and
significance of assessment data
and observations made by LPNs
 Develops or alters the
individualized plan of care as
appropriate to the patient condition
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Duties of the LPN
Make observations
Collect data
Perform simple assessments
Reports abnormal findings
Completes tasks delegated by RN
Documents observations made, data
collected, nursing care given and patient
responses to care
Documents reports of any problems, issues
and abnormal findings to the RN
Nursing Process
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Assessment of the patient
Develop a plan of care
Implement the plan of care
including interventions that are
appropriate for the results of the
nursing assessment
Evaluation of the plan or the
interventions implemented
Communication and
documentation with the rest of the
health care team
What do patients want?
90% of time patients do not tell you that
they are unhappy
Action to Take - LEARN
 Listen to the patient and customer with
sincerity
 Empathize with their situation
 Apologize for their experience or the
mistake if one has been made
 Respond with an appropriate action
 Nurture the relationship
and follow up
Documentation
Reflects the care given to the patient
Demonstrates results (outcomes)
from interventions
Identifies changes in the patient
condition
Reflects changes in the level of
care
Facilitates planning and
implementation of quality and safe
patient care
Documentation
Coordinates care given by each member of
the health care team
Provides a place for an exchange in the
information regarding the patient’s condition
and treatments
Provides data for risk management, utilization
review, case management, quality
improvement, reimbursement and research
What to Document
Any intervention or action done in response
to a problem
Procedures, treatments and medications
including when they were done
Patient’s response to interventions and
medications
Anything that you use to protect the patient
Any observation or assessment made
The care you have given
What to Document
Variations from assessments and
changes to the plan of care
Communication with other members of
the health care team including providers
and attempts to reach care providers
Content and patient response to patient
education
Statements made by the patient
What to Document
Interventions done to make the patient
more comfortable
Acceptance and transfer of care
(report)
Each entry to have date and time
Signature in document that reflects
professional standing
Steps taken to solve a problem
Use correct spelling and grammar
Late Entries
Legal and permissible
Usually considered late entry
within the shift or one shift later
Days after = Addendum
Must be dated and timed at the
time the note is actually written
Become less credible the
LONGER you wait to write them
Recreation of Events
Legal and allowable
Should be written prior to leaving the
institution after event/crisis occurred
Be as detailed as possible
Factual
Common Documentation Errors
Use of labels (names) to describe
patient behavior
Reference to staffing
Reference to filing a QA report
Words used to try to explain mistake
“accidentally”, “somehow”
Editorial comments – dirty laundry
Common Documentation Errors
Charting that you “informed” when you
have only mentioned it
Referring to another patient by name
Vague entries
Omitting consultations with other peers
and members of the health care team
Sample Chart Notes
Pt is a 23 y.o. G6 P5. Past hx of active
drug use. Screaming and crying like a
toddler having a temper tantrum.
Demanding an epidural but refusing to
have IV placed. Unable to monitor baby
due to patient flailing around.
Sample Charting
38 y.o. G4 P0 arrived via ambulance, transfer from St.
Elsewhere. IV of Magnesium Sulfate running into
peripheral L hand IV without infusion pump. Pt nonarousal with respirations of 10 and Sa02 of 92% .
FHR tracing shows baseline of 90 with absent
variability. Magnesium sulfate discontinued, 02
applied at 10 L via non-rebreather mask, patient
repositioned to left side. L. Fabulous RN, charge
nurse aware and at bedside. Dr.No Pain, anesthesia,
and Dr. O.Bee, attending paged and requested to
come stat. Orders received for stat administration of
Calcium gluconate. Labs drawn and sent for stat Mag
level.
Documentation Exercise
Patient is 16 year old G2 P1. Had an
SAB 8 months ago at 16 weeks. She is
now 26 weeks with PPROM 3 days ago.
She is now having bleeding from her
vagina and feels the need to have a
bowel movement. You place the fetal
monitor on her and find the following
strip:
Documentation Exercise FHR
Strip
Documentation Exercise
Let’s document in SBAR format the
assessment of the strip and role play
the conversation that you may have with
the MD/provider.
Include what your
recommendation/request is
1. The patient refused autopsy.
2. Note: patient here-recovering from forehead cut. Patient became very angry when given an
enema by mistake.
3. Patient has chest pain if she lies on her left side for over a year.
4. The patient has been depressed since she began seeing me in 1993.
5. Discharge status: Alive but without permission
6. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
7. The patient had fowl discharge from the vagina
8. She is numb from her toes down
9. Foley draining urine the color of fine red wine
10. The patient had fowl discharge from the vagina
11. The skin was moist and dry.
12. Patient has cccasional, constant, infrequent headaches.
12. Patient was alert and unresponsive.
13. Rectal examination revealed a normal size thyroid.
14. She stated that she had been constipated for most of her life, until she got a divorce.
15. Examination of genitalia reveals that he is circus sized.
16. The lab test indicated abnormal lover function.
17. Skin: somewhat pale but present.
18. Patient has two teenage children, but no other abnormalities.
19. “I had a kiwi on my chest” (keloid)
20. Pt is in homodynamic compromise
21. “Pt denies any rectal breeding”
References
American Nurses Association (1996). Registered Professional Nurses and
Unlicensed Assistive Personnel. Number NP-89 5M Washington, D.C.: ANA.
Fiesta, J (1993). Legal Aspects-Standards of care. Part I Nursing
Management, 24(6), pp.22-24.
Fiesta, J (1993). Legal Aspects-Standards of care. Part III Nursing
Management, 24(7), pp. 16-17).
Fiesta, J(1998). Failure To Communicate. Nursing Management, 29(1), 2223.
Institute of Medicine (2000). To Err is Human, Washington, D.C.: National
Academy Press.
Mahlmeister, L. (2000). The Process of Triage in Perinatal Settings: Clinical
and Legal Issues. Journal of Perinatal and Neonatal Nursing, 13(4).
Mahlmeister, L (1996). Legal Issues in Nursing and Health Care. In B. Cherry
and S. Jacobs (Eds). Contemporary Nursing Issues, Trends and
Management (pp 237-281). St. Louise, MO: Mosby, Inc.
Raines, D. (2000). Making Mistakes. AWHONN Lifelines, 4(1), pp. 35-39