Is documentation part of client care?
Yes! Nursing documentation is recognized as an important duty underscoring professional autonomy.
How does poor documentation reflect upon a nurse ?
Poor documentation portrays a nurse that is inadequate, unprofessional, & incompetent
What are the 9 purposes of nursing documentation?
- Ensuring continuity and quality of care through communication
- Furnishing legal evidence of the process and outcomes of care
- Supporting the evaluation of the quality, efficiency and effectiveness of patient care
- Providing evidence for research, financial and ethical quality-assurance purposes
- Providing the database infrastructure supporting development of nursing knowledge
- Assisting in establishing benchmarks for the development of nursing education and standards of clinical practice
- Ensuring the appropriate financial reimbursement
- Providing the database for planning future healthcare
- Providing the database for other purposes such as risk management and protection of patients’ rights
Describe some documentation issues.
- Nursing process (not incorporated)
- Nurse performance (knowledge)
- Daily tasks (direct/indirect patient care)
- Management (support)
Describe some hindrances to documentation practice.
- Forms/systems may be inconvenient, redundant, inconsistent, lengthy and time consuming
- Forms often do not reflect amount of nursing care provided
- Forms vary between hospital departments
- Often inappropriate for the workload or responsibilities of clinical nurses
Describe some documentation complexities.
- Disruption
- Incompleteness
- Inappropriate
- Nurse confidence & capabilities
- Nursing procedures & workloads
- Inadequate nursing audits
What is the mission of the National Practitioner Data Bank (NPDB)?
To protect the public by restricting the ability of unethical or incompetent practitioners to move from State to State without disclosure or discovery of previously damaging or incompetent performance.
Define Malpractice.
An intentional act (or negligence) committed by a nurse that causes physical, financial, cognitive, emotional, or psychosocial damage to a patient under their care.
Which category of nurses are responsible for the highest percentage of malpractice payments?
Non-specialized RN (62.7%)
What are some issues that contribute to liability risks?
- Improper supervision/delegation
- Early patient discharge
- Nursing shortage
- Hospital downsizing
- Increased autonomy
- Advanced technology
- Better informed consumers
Define Tort.
- Area of civil law that encompasses negligence, personal injury, and medical malpractice.
- A wrongful act that is committed by someone (or an entity) that causes injury to another person or property.
What are the 4 areas that must be proven in a case of negligence?
- Duty
- Breach of duty
- Proximal cause
- Damages or injury
What is the definition of negligence, and what does the JCAHO add to the general definition?
- Failure to use such care as a reasonably prudent and careful person would use under similar circumstances.
- JCAHO adds a additional ‘element’:
Foreseeability
When does Duty occur, and when is it owed to a client?
- Usually occurs when the Nurse accepts responsibility for the care and treatment of a patient.
- Duty of care is owed to a patient when the nurse engages in an activity where he/she is under legal duty to act as a reasonable and prudent person.
What is Breach of Duty?
- Breach of duty or standard of care is determined by proving an act of omission or commission resulted in damages or injury to the patient.
- Nurse’s care falls below the acceptable standard of care owed to a patient.
What is Forseeability (JCAHO)?
What does it not include?
- The nurse has the responsibility to foresee harm and take actions to eliminate the risk.
- The nurse does NOT need to foresee events that are ‘merely possible’; only those that are ‘reasonably foreseeable’.
What is Proximate Cause, and how does it relate to healthcare?
- Causal connection must be evident between the breach of duty and the damages or injury that occurred.
- In healthcare, causation builds upon cause-in-fact and foreseeability.
List some types of Damages or Injuries.
- Loss love/affection
- Loss nurturance
- Pain & suffering
- Mental anguish
- Loss survivability
- Emotional stress
- Disfigurement
- Loss of wages
- Loss of life enjoyment
- Premature death
What are Damages/ Injuries directly related to, and what are the 3 basic types?
- The negligent act of the Nurse defendant
- Types: physical, $, emotional
List the Charting Requirements.
- Chronological
- Comprehensive
- Complete
- Concise
- Descriptive
- Legally aware
- Legible
- Relevance
- Standard (abbreviations, symbols & terms)
- Thorough
- Timely
What needs to be charted, according to the rules? Elaborate.
Chart EVERYTHING!
- Observations
- Nursing actions
- Patient response to therapy & treatment
- Unusual incidents or omitted treatments
- Safety precautions taken to protect patient
- All attempts to reach the physician
- Reservations about medical orders
- Date & time of each entry
- Patients name & ID number on each page
- Your signature on each entry
What could happen if you leave blanks or omit information on charts?
Leaving blanks or omitting documentation could have disastrous results in a lawsuit against you.
Describe some charting “don’ts.”
- DON’T make derogatory remarks r/t pt
- DON’T write irrelevant information
- DON’T criticize another practitioner
- DON’T include extraneous information
- DON’T ever use humor or bias statements
- DON’T write MeQuim filed
What is the “Witness that never lies, dies or moves?”
The medical record
