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Understand nursing practice acts

In a sometimes chaotic environment where nurses are pulled in many different directions to dispense compassion and skill and where policies and guidelines aren't altogether prescriptive about what's to be documented, nurses often raise the question of what must be documented. (See What must be documented....)

Keep your audience in mind

Many cases brought to litigation in the malpractice arena hinge on poor communication between healthcare providers of the same and different disciplines. Handoffs to subsequent caretakers for continuation of care are of particular concern. Because of the variation in interpreting some of the requirements, it may be helpful to back up and see how documentation fits into the overall picture. The first thing a nurse should be aware of is who will be reading the document and why, including:

* the healthcare team. Other members of the healthcare team will be reading the document, so it's important to provide information about the patient that's accurate and complete, reflecting a picture of the patient while under the watch of each nurse. The overall goal of nursing documentation is to create an illustrated timeline for the care of the patient. This means that each entry by each member of the healthcare team must be integrated. Documentation uses words to paint a picture of the patient at specific time intervals and assists subsequent and interdisciplinary caretakers in determining if and to what extent changes have occurred in the patient's status. Therefore, documentation is the creation of a legal document reflecting optimal patient care given in accordance with appropriate standards of care.

* lawyers and experts. The nurse's documentation is read by lawyers and experts when a lawsuit ensues. Every microscopic detail of the medical record is examined by the lawyers and the expert nurses that they employ to make a case for their side. They're looking to see what went wrong and what could have been done better. The goal is to provide complete and accurate documentation about patient care that was rendered according to acceptable standards of nursing care.

* the judge and jury. The nurse's documentation may also be read by nonnursing or nonmedical jurors deciding a case. These cases are already seen as complex and confusing to someone that isn't familiar with the healthcare world. This is another reason why it's important to be succinct and clear with all entries.

Follow the nursing process

The following pointers may help to guide the nurse in documenting completely and accurately while avoiding some common mistakes.

* Never document an acute abnormality found during assessment without documenting the intervention initiated. Example: If a detailed assessment reveals chest pain, then the intervention (such as implementing an order for nitroglycerin administration) and evaluation should follow.

* Never document the intervention initiated without documenting the evaluation/response of the patient. Example: For a patient with chest pain, the intervention that's documented should be followed by an evaluation as to the efficacy of the intervention. Was the nitroglycerin successful at relieving the chest pain?

* Never document a body system abnormality without elaboration. Example: If a patient presents post-motor vehicle accident with a neurologic deficit in the lower extremities (possible spinal cord injury), it's vital to note the details. Over a period of time, the deficit may worsen and with each assessment, the severity should be noted (such as numbness versus inability to move). In this example, the undetected exacerbation of the deficit could result in permanent damage.

* Always document the patient's baseline mental status (if known). Example: A patient who presents with altered mental status who's normally altered should be evaluated for the specifics of his condition. The fact that he thinks the year is 1960 may be normal for him, but it may be significant if he's normally oriented to time. Simply attributing any abnormalities found in mental status to the fact that the patient is normally altered may lead to missed indicators of an acute illness or injury.

* Don't confuse visual, audible, and tactile assessment. Example: Although it sounds simple, it's vital that the nurse documents exactly the sensory method used in assessment. If the patient has a normal breathing pattern as evidenced by sight, then the nurse shouldn't document that bilateral breath sounds were clear to auscultation unless a stethoscope was used to reveal evidence by hearing.

* Reconcile mismatched objective and subjective assessment findings. Example: Pain is a subjective assessment when stated by the patient. If a patient reports a 10 on a pain scale of 1 to 10, this reflects that he's in severe pain. But, if he's sitting up in bed playing cards with a family member at the bedside, this picture is drastically different than if he were diaphoretic and writhing in pain. In both scenarios, the patient may report pain as a 10 out of 10. To track changes in the objective data, the nurse should reconcile via documentation when subjective and objective data don't match.

* Don't become complacent with check-off assessments. Every facility has some sort of check box system for documenting the patient assessment. It's vital that documentation be reflected as accurately as possible. Example: There's no single way to undermine credibility in court more powerful than documenting that a patient with a right below-the-knee amputation has bilateral pedal pulses that are strong and equal. All other parts of the assessment will have doubt shed on them related to the nurse's error in accurate documentation of this issue.

* Always assess the patient at the time of discharge or transfer. It's vital to know the status of a patient before he leaves or enters your care.

* Always use a chronologic documentation format, providing separate entries for each narrative item. Block charting, or charting that doesn't separate each activity by timed entry, doesn't provide a clear picture of the sequence of events surrounding the care of the patient.

* Never use medical terminology unless the meaning of the word is known.When in doubt, spell it out. Be familiar with your institution's policies and procedures related to acceptable abbreviations.

* Use quantifiable data with descriptions. Reference to common objects, such as a quarter or soda can, to describe the size or shape of wounds may be useful with awkward shapes or when there isn't access to a measurement device.

* Always write legibly. There's no single factor regarding documentation that bears more importance than the ability of the audience to read what's written.

* Ensure that late entries should follow your facility's policy.

Complete and accurate is the key

Nurses must know state law and the policies and professional standards related to the specialty in which they practice. When in doubt, a mentor, supervisor, or expert should be consulted to clarify any points of confusion. Most importantly, nurses should document based on evidence-based practice and the standards of care of a reasonable and prudent nurse.

References

Using one state's example, the specific items required by the Texas Administrative Code Title 22 Part II Section 217.11(1)(D) include:

* status of the patient (assessments)

* nursing care rendered to the patient (what was done to or for the patient) physician/dentist/healthcare provider orders

The answer is that anything that will create a more defined picture of the patient should be documented.

References