Transcript Documentation - Birmingham Area WOC (ET) Nurses Association

Nursing and the Law:
“Documentation & Nursing
Malpractice, Are You Protected?”
Presented by
CARTHENIA W. JEFFERSON, RN, CNN, ESQ.
JEFFERSON LAW FIRM, LLC
2107 5th Avenue North
Suite 300
Birmingham, Alabama 35203
Phone: 205.324.1505
Fax: 205.324.1506
Email: [email protected]
DISCLAIMER:

This presentation is to inform you of your potential liability exposure
in the nursing practice. It reflects general principle information only.
It is not to be construed or intended to offer legal advice. Should
you need legal advice or have specific concerns, please consult with
an Attorney. Neither the Jefferson Law Firm, LLC, Nurses Service
Organization, or CNA insurance companies assume any liability for
how this information is applied in practice or the accuracy of this
information. The CNA professional liability insurance for nurses is
underwritten by American Casualty Company of Reading,
Pennsylvania, a CNA company. CNA is a registered service mark and
trade name of CAN Financial Corporation. This presentation was
published in part by information from Affinity Insurance Inc.
Healthcare Providers Service Organization is a division, and Nurses
Service Organization is a registered trade name of Affinity Insurance
Services, Inc
NURSING AND THE LAW:
“Documentation& Nursing Malpractice,
Are You Protected”
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OBJECTIVES
Increase awareness concerning Nursing Malpractice.
Increase awareness of risks, specifically targeting
exposure to nursing negligence and malpractice, i.e.
documentation.
Enhance the quality of documentation by expanding
awareness in order to provide quality patient care and
avoid malpractice incidents.
To address the documentation steps in order to
implement, and thus protect your patient from harm and
minimize your liability exposure.
Increase awareness of nurses being protected with their
own insurance policy, esp. if working contract.
WHAT IS MALPRACTICE?
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Malpractice is professional
misconduct in the performance of
professional services that results
in liability for negligence and
damages.
Negligence is a form of conduct
that falls below the
professional standard of due
care”.
The standard of care is
established by the average
reasonable nurse practicing in the
same or similar circumstances and
delivering care ro the same or
similar patient.
ELEMENTS OF MALPRACTICE
NURSING MALPRACTICE
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Who can be sued?
Which Nurses are sued?
Why are Nurses sued?
What allegations are
asserted against Nurses
who are sued?
When are Nurses sued?
Where are Nurses sued?
What are the actions
necessary to prevent
litigation?
Nursing Actions to
Prevent Malpractice
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Risk Management Techniques
Effective Communication
Quality Documentation
Compliance with state Nurse
Practice Acts
Adherence to Policies and
Procedures
Appropriate, timely and
accurate Incident Reporting
Maintaining patient
confidentiality through
Confidentiality Protocols
Three Powerful Tools to Combat
Malpractice
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Documentation, Communication and
Reporting; The medical record is
important is a medical malpractice case.
It is considered a legal document and
identifies all patient care. It is the primary
method of communication among
members of the healthcare team.
Risk Management/Quality Assurance
Malpractice Insurance
The First Effective
Tool:
1. Documentation, Communication
& Reporting
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STOP
DOCUMENT
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LOOK
DOCUMENT
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LISTEN
DOCUMENT
Legal Perspective on
Documentation
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Not documented, not
done.
Poorly documented,
poorly done.
Incorrectly
documented,
fraudulent.
Quality Documentation
is Quality Care
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Structured writing typically inspires
structured performance.
Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
DOCUMENTATION
According to the Wound, Ostomy & Continence
Nurses (WOCN) Society standards of care:
 The patient should be holistically addressed,
assessing the skin risk potential using a valid
tool.
 Nutritional status should be addressed.
 The need for speciality devices like support
surfaces should be determined.
 Referrals to another medical speciality practice
such as a dietitian should also be included.
You are what you document
A well-documented patient care
record:
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Protects your patient
Demonstrates to the board of nursing that
you are a competent nurse.
Minimizes the potential of being named as
a defendant in a lawsuit.
Minimizes the potential of a court
appearance if you ARE named in a suit.
Help you win if you go to court.
Considerations for
Quality Documentation
Accurate documentation
Contemporaneous
documentation
Record is a Legal Document;
patient care record
Basis for Reimbursement
Fraudulent documentation
Inappropriate documentation
Documentation Dos and
Don’ts:
10 Risk Management Strategies
Risk Management Strategy 1
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Do not erase.
Do not use “white
out”.
Do not cross out an
error with more
than one line.
Risk Management Strategy 2
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Record only the
facts.
Document only
observed behavior.
Document
healthcare services
rendered.
Risk Management Strategy 3
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Do not write
critical comments.
Do not document
your opinions.
Risk Management Strategy 4
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Begin each entry
with the date and
time and end each
entry with
signature and title.
Example:
(03/31/09 7:50AM - Jane Doe,
BCCNS)
Risk Management
Strategy 5
DO NOT LEAVE BLANK SPACES
With EHRs, you need to put
something in a blank space, N/A,
denies or not observed
Risk Management
Strategy 6
Record all entries legibly and in
ink.
Risk Management Strategy 7
Avoid generalized phrases
such as "bed soaked" or "a large
amount."
Risk Management Strategy 8
If an order is questioned,
document that clarification
was sought and discussed.
Risk Management Strategy 9
Document only your own
observations and patient
services rendered.
Risk Management Strategy 10
Do not permit any visiting
relative or other third-party
access to the patient care
record.
Communication Challenges
Attributes:
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Factual
Accurate
Current
Confidential
Reporting Challenges
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Nurses must
communicate
information about
patients to other
nurses and other
health care workers.
Oral Report
–Typically, conducted
at change of shift.
Documentation/
Written Report
–Completed during
shift.
Documentation Methods
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Charting by Exception
FOCUS
Narrative
SOAP
Electronic
ELECTRONIC HEALTH RECORDS
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Be aware that an electronic health record (EHR)
of everything you document now exists and you
can’t make it go away.
If you have to delete an entry, make sure you
accurately explain why you had to delete
something in a patient’s HER.
Be aware of the perils of pasting and copying in
the EHR.
Avoid using unapproved abbreviations.
Make sure your documentation is always
objective and doesn't impute negative behaviors
or traits to your patient.
The Second Effective Tool:
•Risk Management/
Quality Assurance
Effective Risk
Management Strategies
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Comply with Nurse
Practice Act
Practice Competent
Nursing
Comply with Policies
and Procedures
Follow Appropriate
Incident Reporting
Incident Reporting
Losses can be reduced by
a timely, prudent,
and compassionate
response to an incident!
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Learn Your
Organization’s Guidelines
Examples of
Reportable Incidents
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Patient falls
Medication errors
Equipment failure
Complaint by
patient, family,
visitor
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Treatment-related
injuries
Missed/incorrect
diagnosis
Employee
exposures
BE ALERT!
Report unusual occurrences
Document ONLY the facts
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Report immediately, i.e., within 24
hours.
Do not speculate.
Do not draw conclusions.
Do not document impressions.
Do not document impressions.
QUALITY MONITORING
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Participate in
investigations.
Maintain
confidentiality of all
information.
The Third Effective
Tool:
Malpractice Insurance
Elements of Insurance
What is Insurance?
What is Risk?
What is Loss?
What Risks should be Managed?
Most Frequent Allegations in
Nursing Malpractice
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Treatment and care management
Assessment
Abuse/patient’s rights/professional
misconduct
Medication administration
Monitoring
Actions
if a Litigation is commenced
Provide notice to your
administrator as soon as you
become aware of a potential
claim.
Your Options as a Nurse
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Assume the Risk
Yourself
No cost up front
If there is a claim you will be paying
for it entirely out of pocket
Transfer the risk
through employer
provided coverage
No cost up front
Might not protect you sufficiently, or
protect you against a complaint about
you to the Board of Nursing
Transfer the risk by
purchasing your own
coverage
Designed to protect you and only
you, with NSO it covers complaints to
the Board of Nursing
Minimal cost up front
Ten Steps to Prevent Lawsuits
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Protect the patient
Remain current in your professional knowledge
Utilize the entire nursing process
Document comprehensively
Audit your nursing records
Utilize the skills and competencies you acquired
Delegate patient care judiciously
Know your state nurse practice act
Know your department policy manual
Show kindness and respect
ALABAMA BOARD OF NURSING
ADMINISTRATIVE CODE
610-X-6-.13 Standards For Wound Assessment And Care.
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(1) It is within the scope of a registered nurse or licensed practical nurse practice to perform
wound assessments including, but not limited to, staging of a wound and making determinations
as to whether wounds are present on admission to a healthcare facility pursuant to an approved
standardized procedure, outlined in Rule 610-X-6-.12, Standardized Procedures, including
supervised clinical practice and demonstrated clinical competence, initially and at periodic
intervals.
(2) The minimum training for the registered nurse or licensed practical nurse that performs
selected tasks associated with wound assessment and care shall include: (a) Anatomy, physiology
and pathophysiology. (b) Fluid and electrolyte balance. (c) Equipment and procedures used in
wound assessment and care. (d) Chronic wound differentiation. (e) Risk identification. (f)
Measurement of wound. (g) Stage of wound (h) Condition of the wound bed including: (i)
Tissues. (ii) Exudate. (iii) Edges. (iv) Infection. (i) Skin surrounding the wound. (j) Pain. Nursing
Chapter 610-X-6 Supp. 12/31/09 6-23 (k) Complications, prevention, and nursing intervention. (l)
Identification of any contributing factors including but not limited to: (i) Perfusion/oxygenation (ii)
Nutritional status (iii) Infection (iv) Medications (v) Diabetes (m) Photographing wounds.
(3) The registered nurse and licensed practical nurse may provide wound care beyond their basic
education in accordance with an order from an authorized prescriber and after successful
completion of an organized program of study, supervised clinical practice and demonstrated
clinical competence, initially and at periodic intervals.
(4) The minimum training for the registered nurse and licensed practical nurse performing
selected tasks associated with wound care shall include: (a) Dressing changes including
authorized prescriber ordered medication or topical treatment or topical dressing including: (i)
Chemical debridement. (ii) Enzymatic debridement. (iii) Autolytic debridement. (iv) Application
and maintenance of wound vac therapy. (b) Systemic support including but not limited to (i)
Adequate diet. (ii) Hydration. (iii) Turning and repositioning. Chapter 610-X-6 Nursing Supp.
12/31/09 6-24 (iv) Reducing shear and friction with movement. (v) Incontinence care.
(5) Sharp debridement is reserved for registered nurses with national certification that included
didactic instruction, supervised clinical practice and demonstration of competency, initially and at
periodic intervals. Author: Alabama Board of Nursing Statutory Authority: Code of Ala. 1975,
§§34-21-1(3)(b), 34-21-2(a)(21), 34-21-2(c)(6). History: New Rule: Filed May 21, 2004;
effective June 25, 2004. Repealed and New Rule: Filed November 23, 2009; effective
December 28, 2009.
DOCUMENTATION DO’S AND DON’TS
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1. Do/Don’t Write legibly.
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2. Do/Don’t Check to make sure that you have the right chart
before you begin charting.
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3. Do/Don’t Check before administering a medication to follow the
five rights of medication administration: right patient, right
medication, right route, right dose, right time.
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4. Do/Don’t Alter a patient’s record to prevent from being sued.
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5. Do/Don’t Make sure your documentation reflects the nursing
process and your professional capabilities.
Documentation Bloopers
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“The patient refused an autopsy.”
“The patient has no previous
history of suicides.”
“Patient has left white blood cells
at another hospital.”
“On the second day, the knee was
better, and on the third day it
disappeared.”
“The patient has been depressed
since she began seeing me in
1993.”
“Discharge status: Alive but
without permission.”
“Healthy appearing decrepit 69year old male, mentally alert but
forgetful.”
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“Patient had waffles for breakfast
and anorexia for lunch.”
“She is numb from her toes
down.”
“While in ER, she was examined,
x-rated, and sent home.”
“The skin was moist and dry.”
“Patient was alert and
unresponsive.”
“Rectal examination revealed a
normal size thyroid.”
“She stated that she had been
constipated for most of her life,
until she got a divorce.”
“Skin: somewhat pale but
present.”
“Patient has two teenage children,
but no other abnormalities.”
REFERENCES
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Alabama Board of Nursing:
http://www.alabamaadministrativecode.state.al.
us/docs/nurs/610-X-6.pdf
American Nurses Association (2010). Scope and
Standards of Practice (2nd ed.). Silver Spring MD:
Author.
American Nurses Today:
https://americannursetoday.com/need-knowelectronic-documentation
Legal Issues in Wound Care: medline University,
https://www.medlineuniversity.com/documentati
on/viewdocumentation
DISCLAIMER:
This presentation is to inform you of your potential liability exposure in the
nursing practice. It reflects general principle information only. It is not to be
construed or intended to offer legal advice. Should you need legal advice or
have specific concerns, please consult with an Attorney. Neither the Jefferson
Law Firm, LLC, Nurses Service Organization, or CNA insurance companies
assume any liability for how this information is applied in practice or the
accuracy of this information. The CNA professional liability insurance for nurses
is underwritten by American Casualty Company of Reading, Pennsylvania, a
CNA company. CNA is a registered service mark and trade name of CAN
Financial Corporation. This presentation was published in part by information
from Affinity Insurance Inc. Healthcare Providers Service Organization is a
division, and Nurses Service Organization is a registered trade name of Affinity
Insurance Services, Inc.
THANK YOU!
THE JEFFERSON LAW FIRM, LLC
WHERE WE SERVE WITH “GRACE, JUSTICE AND MERCY”
Phone: 205.324.1505
Fax: 205.324.1506
Email: [email protected]