H

aving served as a legal nurse consultant, I am often asked to review medical records for clients to determine if the actions taken by the nursing home staff were appropriate, reasonable, timely, and/or met professional standards. Often, what is written, what is not written, or the way a note is written provides a sound basis for the prosecuting or defending attorney. Which attorney would benefit from your documentation?

Documentation: Just Paperwork?
       Documenting (entering information into the medical record) is often viewed as unnecessary burdensome paperwork. It is often the last task to be accomplished by the nursing staff in the facility and often determined to be the least important function of one's job. Even administrators have often seen documentation as "busy work" and have not planned or provided adequate time, training, or personnel to accomplish this task appropriately. Since documentation is the only method of showing what occurred on a given date and time, it is sometimes the primary and most important source of information, especially since most legal cases requiring medical record reviews come to court two to three years after the event in question happened. In addition to litigation, medical record review is used during surveys, Medicare audits, reimbursement audits, or insurance investigations to validate necessity and type of care rendered. Also, the Centers for Medicare and Medicaid Services (CMS) utilizes documentation from the Minimum Data Set (MDS) to establish payment rates and identify quality indicators and quality measures.
       When using the medical record to defend one's actions in a court of law or to prove care was necessary to qualify for payment of services, documentation becomes of prime importance. It gives a complete history of a resident's illness, care and services rendered, outcomes of care, and planned care.
       The medical record should be viewed as a paper duplication of the patient and should serve as a means of communication for interdisciplinary team members that represent all actions around the clock.
       The medical record is potentially a public document. Imagine your notes being displayed on a screen large enough to be seen by 12 jurors challenged with the task of deciding if proper care and practices were being followed by the clinician or the facility.

When Documentation can be Your Worst Enemy
       Documentation can be harmful to the facility and the professional when it:
- Reflects poor judgment in care decisions leading to inadequate care (improper or lack of assessment and/or care practices)
- Points out mistakes
- Has insufficient information
- Reflects staff conflict
- Appears to have been tampered
- Has omissions
- Does not "tell the story."

When Documentation can be Your Best Friend
       Documentation can help the facility and/or professional when it:
- Provides clear concise communication of what has been done for the patient and what needs to be done
- Reflects care that was given according to best practice standards and according to facility policies and procedures
- Reflects nursing process (assessment, plan, implementation, evaluation) throughout the record
- "Tells the story."
       Facilities should have systems in place that assure that documentation effectively describes assessment of the patient and what you did for the patient and the response of the patient to your actions. In addition, it should validate necessity and appropriate delivery of care based on adherence to professional standards of care. These professional standards are those recognized by professional agencies, such as Joint Commission, American Nurses Association, as well as governing agencies, such as professional boards (nursing, physician, etc.), and legal practice acts for specific disciplines. Also, protocols established by your institution must be followed and reflected in care and documentation of the care.
       Anyone entering information into the medical record should be familiar with the layout and organization of the medical record. Where are the MDS assessments located? Where are the most current care plans, lab reports, etc.? Often I will ask staff nurses where a routine assessment is located, and they have difficulty knowing where to look. In order for the medical record to be used as a communication tool, staff must know where and what information is communicated.
       Quite often a deterrent to effective documentation occurs for the following reasons:
1. Too much documentation is required of the staff: Often I observe staff having to document on each shift for a resident where there has not been any change of condition or new information on the resident. When I ask why they are doing that, I usually get a response, such as "We have always done it that way."
2. Redundant documentation: I often observe the same piece of information documented in several different places in the chart. For example, I may see a lab result charted on a flow sheet, on a nurses note, on a dietary note, on a doctor progress note, and then possibly on the care plan. If staff members know exactly where this information is to be recorded in one spot, it would not be necessary to record it in five different locations as illustrated in the previous example.
3. Too many different forms on the record requiring the same information: As mentioned in #2 above, many new forms are also added to the medical record requesting the same information and often no forms are discontinued.
4. Staff are not always aware of why or what they should be charting: Some facilities require charting on every shift for their Medicare A patients. In visiting one facility, I went to a skilled unit that only housed Medicare A residents, and I asked several nurses why the person was Medicare A and what should they include in their documentation. The majority did not know; they just knew that they should be charted on every shift. This was not a federal requirement for charting every shift but a facility requirement. Medicare requires that the resident need services rendered by a licensed professional that could not reasonably be done elsewhere. For example, a resident with a fractured hip may be receiving physical therapy, and this may be the service that the staff need to be sure is documented. It may not be necessary for every shift, or any shift, to chart if the therapist was documenting the skilled service in their notes and their notes were part of the medical record. I sometimes ask directors of nursing why they require every shift charting on these residents and am told that if they require it every shift, they are more likely to have it charted at least once a day.
       What can facilities do to enhance documentation practices in the facility?
1. Periodically, facilities need to review all the different forms in the medical record and see if any can be combined or eliminated.
2. Hold discussion and inservice staff during orientation and at least annually on appropriate documentation practices.
3. Provide documentation guidelines for specific events, such as Medicare charting, falls, incidents, admissions, discharges, etc.
4. Develop quality assurance tools that will allow peer audits to check to see if documentation is present and according to acceptable standards of practice.
       In the next issue of ECPN, we will discuss the dos and don'ts of documentation to assure that the medical record will be your best friend--not your worst enemy.