Documenting the Process
Medical Record Documentation and
Legal Aspects for a CNA
A Self-Instructional Program
Approved for 1 Contact Hours
This study was prepared by Linda S. Greenfield, RN, Ph.D.
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Documenting the Process
"The job isn't finished until the paper work is done!" "If it wasn't documented, it wasn't
done." Like it or not, documentation is here to stay. Many never received a clear understanding
of the process of documentation and what was needed. The Florida Administrative Code 64b915.011 and the Nurse Practice Act which governs CNA inservice training state that the CNA
must have12 hours of training every year that includes the following mandatory subjects
every two years: HIV, medical record documentation, communication with the cognitively
impaired, infection control, resident/patient’s rights, CPR, domestic violence and medical error &
safety. This course has been designed to meet the requirement of medical record
documentation.
Please read these IMPORTANT INSTRUCTIONS as they contain answers to many of the
questions we are often asked regarding home study.
If you have downloaded this course, you may save it to your hard drive or print all or any part of it.
In this way the document is available to you as a resource. As you leaf through this study, you will notice
that there are questions placed throughout the reading material. Please notice the last two pages and
print these if you have downloaded the course. The first is an answer sheet. As you complete the study,
record your answers on this sheet. A passing score of 75% must be achieved to receive credit. In the
event that you do not reach 75% on the first submission, you may try a second time without paying
again. You must pay again if you need more than two attempts to pass the course. You may refer to the
material at any time and you may also study in groups, if you wish. The second sheet is an evaluation
form and is to be filled out and submitted along with your answer sheet. If you find any errors, please
note them so we may correct them at the next printing. You may submit your answers online and your
certificate will be available upon successful completion. Or you may fax your answer sheet to 206-6006268, or mail it to: Nurse Learning Center 8910 Miramar Pkwy Miramar, FL 33025. Faxed or mailed
answer sheets are processed within one week of receipt. You receive credit on the date we process your
answer sheet. If you put your fax number on the answer sheet, we will fax back a copy of your certificate
before we put the corrected answer sheet and a certificate of completion in the mail to you.
If you have a certification number (C.N.A. number), put it in the space labeled “License or
Certificate number” and it will print on your certificate. If you do not have either number, just
leave that space blank. Should you decide not to finish the course this year, it can be applied
anytime up to two years from the date of purchase.
Initial Printing: May 2003
Current Revision: May 2010
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Documenting the Process
Objective No. 1: Recognize the five steps of the nursing process in your documentation.
Objective No. 2: Identify aspects of patient care documentation that fulfill each step of
the nursing process.
Objective No. 3. Analyze your system of documentation to determine how well you are
supporting the nursing process for each patient.
INTRODUCTION
You’ve worked hard, and there was much to do. But now you are supposed to chart what you did,
but your mind isn’t cooperating. It went blank. You fight to remember all of the many things you did do.
How will your tired mind organize the data? Where do you begin?
Might I suggest you begin with the nursing process? This is the way patient care is organized, and
showing how each of us contributed to each step of that process is how we show surveying authorities
that we did our job. Patient care documentation is not a haphazard collection of writings. It is written
evidence that the steps of the nursing process are each connected to each other and complete. This is
what every surveyor is trained to look for in nursing home or hospital or home health care settings. The
steps of the nursing process include assessment, diagnosis, planning, intervention, and
evaluation. As an aide, you don’t contribute to ALL of the steps, but you do contribute to several. This
course will help make you aware of how your charting links to everyone else’s charting, and why what
you write is important. The Joint Commission of Health Care Organizations, and HCFA through OBRA
(our surveying agencies) search diligently for evidence of these steps and will read your contributions to
the process.. As the nursing process is the required organization of all documentation by all staff, you
need to analyze your own input to determine that yours is correct and includes what it needs to. This
course is organized according to the steps of the nursing process.
STEP ONE: ASSESSMENT
Both in chronic and in acute care, assessment is really important. Your writing has to show others
that you are always watching your patients, and always checking their condition to see if something has
changed that needs to be communicated to others. You turn the patient over to change his bed and you
notice that he has a skin break on his back. What you noticed is called an “assessment.” You check to
see how much of his dietary supplement the patient drank -- another assessment. You cleaned up the
results of a laxative and noticed with multiple senses the quality and quantity of the patient’s stool. That
is how you are assessing the patient’s condition. Every healthcare worker has their own areas of
assessments. For aides, assessments include how well the patient ate, how often and in what amounts
he voided, what are his vital signs, when was his last bowel movement, what was the condition of his
skin observed during his bath, etc. An assessment is something that describes the patient.
Documenting assessments is easiest with “forms”, “flow sheet” or “checklists”. This means you just
check that he had a bowel movement, or write in today’s weight on a line on a form that asks for that
information. Narrative documentation of an assessment is very time consuming and not usually
necessary. Documentation on “narrative notes” means you write out everything in long hand. So if you
had to document those two things in a narrative, you would have to write out , “Patient had a soft formed
medium bowel movement.” Or “The patient weighs 135 pounds today.” The purpose of any assessment
“form” is to guide you so that the data collected is more complete, and to simplify the process of writing
observations. The form organizes your charting, and is usually easier than writing things out. Many
facilities could improve their documentation simply by revising their assessment forms to be sure that:
 they include needed information that has to be in the documentation,
 any repetition of information is deleted, and
 that there is an assessment form available to meet most of the common situations in which assessment is
required, e.g. how often the nursing home resident tries to elope from the building.
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Documenting the Process
Assessment data is not always recorded on forms or flow sheets. Narrative notes are necessary to
some extent. Whenever you write out details in long hand, ask yourself what your purpose is for this
narrative. Which step or steps of the nursing process are you supporting in your documentation? There
are times when you need to summarize an assessment, and other times when you need to describe an
intervention (something you did) or an evaluation (how well it worked). In fact, the narrative notes may
be the place to summarize the entire nursing process.
The major problem with narrative notes is that they are blank lines that you are supposed to fill with
information. There is no guidance or clues as to what information the reader wants. Forms, check lists,
etc. fulfill this need. Narrative blank lines don't.
For those blank situations, you can use other guides. One is based upon Gordon's 11 Functional
Health Patterns. Gordon, a nursing theorist, provided one of the popular frameworks for nursing, and the
eleven functions of health are listed below. It's a very complete list. If you determine that what is needed
is a summary of assessed data or perhaps documentation of care given, and no form is available, you
can use these 11 functional patterns. The first letter from each health pattern creates an acronym
(C/PRIME CRAVES), that you can list on your workbook until you are very familiar with them.
C/P
cognitive/perceptual (Aspects of thinking or perceiving. This kind of data is very
important when the patient has a disease like dementia and he can’t think appropriately, or he has had a
stroke and his perceptions are off, such as when he sees only half of the room)
R
rest
I
intake
M
management (health) (This kind of data refers to how well he completes his activities of
daily living. Can he care for himself? Did you have to help with some tasks?)
E
exercise
C
coping
R
roles (This kind of data has to do with his relationships with others or with his identity.
Maybe he’s having trouble letting other people take care of him.)
A
awareness (self)
V
values (This kind of data has to do with the things the patient feels are really important.
For example maybe he values smoking but he has to be a patient in a non-smoking facility. This might
create some care issues.)
E
elimination
S
sexual
Using this as a guide, you can improve the quality of your narrative summary of the care you
provided. For example, my patient is an Alzheimer's patient. My healthcare company requires weekly
summary charting for his level of care. The care plans are evaluated on another form, so the purpose of
the summary charting in this situation seems to be the assessment step, unless there are interventions
needing description. Here's an example of how "C/Prime Craves" can help you chart a narrative that
emphasizes assessment. The bolded categories are added for your clarification, but are not included in
the charting.
"Disoriented to time and place. Short attention span. No evidence of pain or discomfort.
(Cognitive & Perception) Anxiety low. Able to rest and sleep when in quiet, darkened room. (Rest)
Appetite good. Eats 100% most of the time. (Intake) Requires complete assistance by staff or family for
cares. (Health management) Exercises frequently through monitored pacing. (Exercise) Frequent
nurturing offered and accepted with hugs and touch. (Coping) Responds to name only if used with
touch. Eyes cast downward most of time. (Awareness) No longer recognizes family and seems unaware
of them for the most part. (Roles) Continent of bowel and bladder. Skin kept clean and dry. Skin intact
and normal pink. (Elimination)" (The two areas not spoken to are values and beliefs, and sexuality,
both very difficult to assess in this stage of Alzheimer's.)
The ability to effectively document assessed findings has become vital to get financial
reimbursement for the facilities we work for. In most systems, assessment is linked in some manner to
reimbursement from third party payors. This is the case with the MDS (a required assessment tool in
long term care facilities), and OASIS (required in home health care). After the nurse or other providers
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Documenting the Process
complete the MDS/ OASIS requirements, the Health Care Financing Administration (HCFA) software
electronically classifies the patient, according to the assessed findings. Within each class there are
further divisions of Medicare and Medicaid groupings. HCFA weighs the nursing care time used to do
specific tasks and allocates reimbursement according to averages. Thus, documentation of skilled
assessment has become a quality, legal, and reimbursement issue. It is important that you learn to
document what you do carefully with an idea of how your documentation fits into the whole process.
Assessment is a hot spot for surveying agencies. Make sure you are writing down the many things
you do see, even if you told the nurse. Write that you told the nurse and what you told the nurse in your
assigned papers for documentation. Continually be on the lookout for evidence of change or to monitor
patient safety. Whenever you discover something different, report it and chart it. The most efficient way
to accomplish this step is the use of forms with checklists, and short comments
Question No. 1: Which of the following is NOT true?
a. C.N.A.s rarely do assessments.
b. If you checked a box on a form that indicates the patient had a bowel movement today,
you have documented an assessment.
c. If you wrote out on a form, “Patient had a bowel movement,” you have documented a
narrative note.
d. It is necessary to write out some changes you observe when there is no place on a form or
a checklist for this information.
Question No. 2: Which of these describe “the nursing process?”
a. Each step of the nursing process leads to the next step – they are connected.
b. It involves five steps.
c. This is a way patient care is organized.
d. All of these describe the nursing process.
Question No. 3: What does the “I” in C/PRIME CRAVES represent?
a. Income.
b. Intake
c. Intervention
d. “I” –self awareness.
Question No. 4: All of the following are examples of assessments often done by CNAs. Which is
NOT?
a. How much a patient ate.
b. If you changed the bed today.
c. The patient’s weight.
d. Vital signs.
STEP TWO: NURSING DIAGNOSIS
When something abnormal is discovered during an assessment, the next step of the nursing
process is to organize that data into a problem list, or nursing diagnoses. Although problem lists were
used frequently in the past, today the use of specific nursing diagnosis terminology is encouraged. The
nurses usually do this in a care plan format. In some facilities, your charting forms might be organized
according to the nursing problems or diagnoses.
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Documenting the Process
Once a problem is recognized (someone charted new assessment data), it must be followed
through the whole nursing process until it is resolved. So the identification of abnormal data leads to
naming or describing the problem, which leads to a need to do something about it. This particular step of
documentation, the diagnosis, is not usually within the aide’s realm of responsibility to write or create, but
it is important for you to understand how everything is linked, and often you are the one finding the
problem. When you read the care plans you will find nursing diagnoses or problem lists.
So, for example, you might chart (and report to the nurse) that your patient has a small place on her
coccyx where the skin has broken down. This is a new finding. Once this is discovered and charted, the
nursing process must be followed all the way through, and the surveyor has to be able to read in the
chart every step. After the new discovery (the skin breakdown) someone (usually the nurse) has to put it
on the problem list. She might just list the problem, like “#7: Skin breakdown.” Or she might write a formal
nursing diagnosis: “#7 Impaired Skin Integrity related to immobility evidenced by a 2 cm break in the skin
at the base of the coccyx.”
In some facilities, documentation is computerized. Standardization is much easier to computerize.
It is impossible for a computer program to know how to sort or organize data, if each healthcare worker
uses her own words to describe a patient problem to the computer. Due to the increased requirements
for documentation, computerization use will increase, which is requiring us to all learn a specific
terminology set in order to be uniform (e.g .the formal nursing diagnosis). These are precise phrases that
have to be used, such as “Potential for fluid volume deficit.” You can begin to recognize the use of
nursing diagnoses and problem lists as a way to organize the data. Nursing diagnosis terminology can
seem overly complex and often confusing. The words often have to be interpreted. You might have to
ask, “What does “impaired skin integrity” mean. (A break in the skin). This is true for many of the
diagnoses. “Fluid volume deficit” is another common diagnosis. It means the patient is dehydrated. It is
a common problem with nursing diagnoses. If you read a care plan and you can’t figure out what the
problem is, ask someone. It is difficult for most of us to understand. Learn to ask until you become
familiar with the phrases that are used.
Question No. 5: If you read on a patient’s care plan, “Fluid Volume Deficit,” this means:
a. That the patient’s problem is dehydration.
b. This is a precise phrase that has to be used, especially with computers.
c. This is called a “nursing diagnosis.”
d. All of these are part of the meaning of “Fluid Volume Deficit.”
STEP THREE: PLAN OF CARE
Once our diagnoses or problem lists are made, the next step in the nursing process is the plan of
care—which is a list of what we are going to do about the problem. Care must be adequately planned
and outcome-oriented. That means that each problem has goals attached to it. Mostly nurses complete
this step, but you can recognize how your documentation of what you observed (assessments) fit into the
process, and you are supposed to be reading the plans so that you are aware of the patient’s plan of
care. Every patient has a care plan, but different facilities store them in different places. One common
place is on the patient’s chart, but in some work environments, aides don’t have access to the charts. So
another place might be in a notebook that everyone can access.
Whatever document fulfills this planning step of the nursing process, it must list the 1) patient's
problems, 2) specific interventions (the “to do” list), and 3) goals or outcomes. Attention will then be given
to evaluating how the patient is doing with this plan. Assessment, whether it is before the plan or to
evaluate the plan, is where the emphasis is in all health care environments.
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All staff should be able to describe the planning process, and the facility needs specific policies and
procedures that describe:
 how soon after the assessment the care plan will be completed,
 what documents are involved in the plan of care for each discipline,
 who is responsible to develop the plan of care and for updating it,
 how ongoing assessments data is incorporated into the plan,
 the minimum time frame for reviewing the plan of care, and
 how the plan is updated to reflect changes in the patient's condition.
The plan of care usually has three elements -- D.I.G: Diagnosis, Intervention and Goal. “D” –
diagnosis – is the nursing diagnosis you just read about. “I” – interventions – is a list of things to do to
help the problem, and “G” – goals – is how we know the plan is working or not. For example, if the
patient has had a stroke, as a result of his brain trauma and immobility (he can’t feed himself), he may be
becoming dehydrated, or have that potential. The care plan may read as follows:
D: Potential fluid volume deficit related to immobility and inaccessibility of fluids. (This means he is at risk
for dehydration because of his immobility.
I:
(These are all things you are responsible for, and the care plan tells you what you have to do.)
1. Measure and record intake and output every 8 hours.
2. Assist patient to drink every 30 minutes during waking hours.
3. Provide 2000 cc of fluid every 24 hours.
G: Patient will not have dehydration as evidenced by good skin turgor and moist mucous membranes,
and intake greater than output, when assessed every 8 hrs.
The interventions are a list of things to do to solve the problem. They are specific enough to be
followed by any who read the plan. "Force fluids" is not specific. The interventions should be discipline
specific. Who is responsible to ambulate the patient: physical therapy or nursing (either the nurse or the
CNA)? Who will do the dietary instruction: the dietitian or nursing? Especially in home health care, the
frequency and duration of services is part of the detail provided in interventions.
The goals are usually measurable, and they need to be specific, objective, reasonable, and related
to patient care. Goals also may be subdivided into discipline-specific goals. It would help you to read
and know what the goals are for the care you are to provide.
Consider how you would follow the nursing process in your care. For example, let's say that you
often work without a nurse nearby. You discover the patient is developing a cold, and you call the nurse
for some decongestant or cough suppressant drug order to help him feel better and allow some sleep. In
your charting you describe the clustered symptoms (the problem), and what you did about the problem
(notify the nurse on call). Then you need to describe the outcome in terms of patient expectations (to
clear airway enough to allow adequate rest during the night). So what you chart might read, “Patient
complained of a stuffy head, sore throat, and runny nose. TPR is 99.6, 104, 24. B/P 134/90. Nursing
supervisor notified. The nurse talked to the patient on the phone, instructing him to take cough syrup now
to help clear the airway and allow the patient adequate rest during the night.” You have charted your
assessment (all of his symptoms), your interventions (you called the nurse) and planned interventions
(he’s going to follow the nurse’s instructions), and the desired outcome (he can sleep). If you only
charted, "patient coming down with a cold. Nurse supervisor called," you would make errors. First you
made a medical diagnosis (the cold). Then you listed the intervention, but not the outcome in terms of
what you expect for the patient.
Consider documentation of the planning step from another perspective. Even though you might be
removed from writing the official patient care plan, you must show evidence that you use the care plan.
Documentation MUST consider the patient's care plan in order to be complete. It is vital to the
documentation process. The care plan is the central core to documentation, and it is the guide to
documentation. The care plan tells us what to document and how often to do it. The more specific the
care plan, the more it offers guidance. For example, with the potentially dehydrated patient above, it will
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be important to document somewhere that he was offered some fluid every 30 minutes while he was
awake (assuming that this is true.) Basically, if the care plan states something is to be done for the
patient at a precise interval (e.g. every 8 hours), there had better be follow-up documentation stating it
was done, and how effective it was, i.e. the care plan determines how you will chart the last two steps of
the nursing process: interventions and evaluation. Documentation has to show a "flow" from assessment
to diagnosis, to plan, to interventions given or not given as planned, to evaluation; all linked together.
You should be told what parts of this documentation are your responsibility. The nurse carries most of
the responsibility, but if you are there asking the patient how much he drank since lunch, you need to
recognize that it is important to write down what the patient told you, probably on an intake/output form.
Obviously, if the care plan is to succeed as a guide to documentation, it needs to be reasonable
and applicable to actual patient care. It is vital that there be good communication between those
establishing the standards for care (and documentation) by writing the care plan, and those providing
that care. You have a lot of information to offer because you are with the patient more than anyone else.
Find out who writes your care plans and learn how you can provide input into that process.
As you work with the care plans, you will increasingly be able to recognize errors, and to recognize
ways in which the care plan tells you what and when to document. If the care plan indicates you will
assess some parameter (e.g. urine output) every so many hours, and this is not documented, then this is
an error in documentation, and a "hole" which surveying agencies and audit committees look for.
Question No. 6: All of the following guide you in knowing what to write, except one. Which is not
true?
a. Look at the goals and write evidence indicating you are moving toward or away from the
stated goals.
b. Look at what you wrote last week and write the same thing again.
c. Look at the list of cares (intervention) that you were responsible for and describe on the
chart how it went.
d. All of these are way the care plan guides you in knowing what to write.
Question No. 7: True or False? A care plan is a list of staff problems, like who’s going to take care
of these patients?
a. True.
b. False.
Question No. 8: These all describe what CNAs have to do with care plans. Which one is NOT true?
a. Changes in patients are often observed by CNAs and brought to the nurse’s attention so
that s/he can create a plan of action – a care plan.
b. CNAs are responsible for doing many of the things that are planned – the interventions.
c. CNAs often are responsible for writing the care plans.
d. We are all supposed to be reading and using the care plans.
Question No. 9: Which describe the “Interventions” written on a care plan?
a. This is a description of the problem, the nursing diagnosis.
b. This is a measurement of how well the plan is working.
c. This is the “to do” list.
d. All of these describe “Interventions.”
Question No. 10: If the care plan states, “Measure and record intake and output every 8 hours”,
then someone needs to write this information on a form every 8 hours.
a. True.
b. False.
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Question No. 11: You find that for the patient in Question 10, two days went by and no one was
recording his intake or output. You checked the care plan and it still read the same. When
you asked the patient, he indicated that he didn’t feel it was important anymore. Which of
the following is true?
a. As long as it is still active on the care plan, this is an error in documentation that you
need to report to the nurse for resolution.
b. As long as the patient doesn’t feel it is important, there are no errors in this situation.
STEP 4 and 5: INTERVENTIONS AND EVALUATIONS
Another word for “interventions” is “actions.” What action did you take? What did you do? Did it
work? That’s what this step is about. Documenting interventions mean you need a way to document what
you did -- actions that may have been required by the care plan. The most efficient way is with a flow
sheet. You currently use several flow sheets and checklists to document standard interventions. Both
acute and chronic care environments utilize some sort of medication flow sheets, in which you initial that
a medication was given as scheduled. Treatment flow sheets are also very common, as are dietary
flowsheets (what did the patient eat), intake and output, and ADL (activities of daily living) flowsheets.
Both interventions and evaluations to be documented are determined, mostly, by the care plan.
Some of these will be on a traditional flow sheet, and some will need comment in the narrative notes. Of
course, there will always be situations, new symptoms, incidents, etc. that are not listed on the care plan,
which require a careful and specific notation of the events, signs and symptoms, actions taken, etc. This
is what narrative notes are for -- unusual circumstances.
As an example of documenting these last two steps of the nursing process, consider some of the
plan-dictated possibilities of a problem that could be applied to a post-stroke patient. First, look at the
problem (nursing diagnosis) and the plan of care.
#1: Impaired swallowing related to stroke evidenced by choking episodes, more so when
swallowing liquids.
-Use "THICK-IT" in all liquids.
-Turn head to encourage food to unaffected side.
-Encourage the patient to concentrate on swallowing, with his tongue on roof of his mouth.
-Alternate hot and cold foods to stimulate nerve functioning.
-Assess for signs and symptoms of aspiration with each intake: wet voice, moist bronchial
sounds, spasmodic coughing.
Patient will be able to complete full tray, without signs or symptoms of aspiration.
Secondly, consider how you might document your “interventions and evaluation of effectiveness” in
such a way that your charting is "linked" with the plan of care.
The goal for #1 is measured by the amount eaten, which is usually indicated on a form. The
amount of aspiration (did he choke when you fed him?) will need to be documented someplace. Maybe
there are blank lines on the amount eaten form in which you could write if he choked or not when you
were feeding him.
With the patient's plan in front of you, it is easy to determine what you need to write. The plan tells
you. If you are responsible to write narrative notes, your summary of the plan of care for this patient
might be: "Ate 75% of supper, with one short episode of coughing. Voice dry, no gurgling sounds heard
following swallows." (You have evaluated both the goal and the care plan for #1, and have basically said
the plan appears to be working.)
If you don't document from your care plans, you will have difficulty supporting the nursing process,
and your facility will have problems. Evaluating agencies look for the assessment, the formation of
nursing diagnosis, the recognition of needed interventions in the form of a plan of some sort, and
documentation that the plan was done and changes made when necessary. Your biggest areas of
responsibility are the assessments (what you observed) and giving the care, followed by reporting how
that went.
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There might be breakdowns in communication between the aides, the nurses, and others that
allows the nursing process to fail. The whole process of documentation centers on the patient’s care
plan. Let me provide an example problem from a long-term care environment on the evening shift. It is
the nurse who commonly completes the more detailed assessment forms, but it is the aide who cares for
and rehabilitates the patient. When the nurse completes an assessment form like the MDS, some
problems are found, such as incontinence of urine, for example. Because incontinence is not normal, a
care plan problem is created with directions about what you should do about it. There are bowel and
bladder function assessment forms that are completed by the aides and signed by the nurse, and in this
case, the care plan says that the patient has to be taken to the bathroom every two hours, and that she’ll
be praised for appropriate functioning, etc. In many long-term care facilities, most patients need to go to
the bathroom at the same time, right after supper, and most are not freely ambulatory. They need help.
At the same time these people want to go to bed, so naturally after they go to the bathroom, they don't
want to return to their chairs. With standard staffing, it is physically impossible to take them all to the
bathroom in time. The best that most staff can do is to help the more independent and mentally aware,
and maintain good skin condition on the others, who will be incontinent because there isn’t time to get
them to the bathroom as quickly as they need. Even if staff ratios were perfect, I'm not sure it’s a good
idea to try to keep all of them continent. Their level of confusion increases as anxiety increases. With
multiple trips to the confining bathroom, attempts to remove clothing, and limited ability to understand our
requests that they "go to the bathroom", anxiety increases. In some cases, their quality of life would be
improved if we would accept the incontinence, maintain skin integrity and cleanliness, and seek to
reduce anxiety.
In this example long-term care facility, neither the staff nurses, nor the aides write the care plans.
They are written by a committee. But in any healthcare environment, all staff have to do what the care
plan says to do and describe how well that is working in the charting. So in this example, the staff are
asked to evaluate the care plan that states they will toilet the patient every two hours. But she wasn’t
toileted every two hours because that time was given to more mentally alert residents. Now the staff are
between that proverbial "rock and hard place." Do they chart that the patient was taken to the bathroom
every two hours, when she wasn't? Obviously NO. Do they chart that the patient was not taken to the
bathroom because there were not enough staff hours to accomplish it? NO, again. Do they just chart
the patient wasn't taken to the bathroom, and leave the reason blank? How do they win this one?
Neither can they chart that the patient’s anxiety increases with frequent attempts to take her to the
bathroom, if they can't get her to the bathroom often enough to observe the behaviors. The staff
suspects it would happen because of multiple times in the past with this and multiple other patients, but
with the need to frequently assess and evaluate the care plan, they would have to keep proving it, at the
patient's expense.
This is exactly why it is important that those writing the care plan get input from those providing the
care (you). That means that you-who-give-the-care need to communicate well with those-who-write-thecare-plans when what is written is unrealistic or not working. You do that with your charting, in part. With
clear documentation, you can support with evidence why incontinence should NOT be care planned on
some specific patients, shifting the trigger emphasis to one of preventing skin breakdown. In the above
scenario, you would not check the box that indicates she was taken to the bathroom every two hours if
you didn’t do it. Not checking the box means that you have to provide some explanation of why you
didn’t give this care. You would then write an explanatory note that states what happened without
indicating blame. For example, “Patient frequently incontinent. Skin kept clean and dry. Skin intact.
Incontinence reported to the nurse.” Then in verbal communication with your nurse you could point out
that the care plan says toilet every two hours, but for all the reasons you can list that it was not working.
It would not be legally safe to imply there was a lack of time or a lack of staffing. That’s a facility problem
not a patient problem. In the chart we are only concerned with patient problems. For example, to say,
“Patient not taken to the bathroom because no one has the time,” would be a major red flag and bad
charting. And to lie and indicate you did take the patient to the bathroom when you didn’t is obviously
bad. A successful resolution would be for the care-planning committee to recognize the this particular
patient does not do well with incontinence training, and to change the problem to the potential for skin
breakdown and the plan to keep the patient clean and dry. This you can do and you can chart about it.
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Documenting the Process
But someone has to provide the communication, and since you are the one responsible to take her to the
bathroom, you are the one to provide that needed communication.
Documentation of the nursing process is a carefully linked, closely integrated task, requiring the
cooperation of all staff members. You need to provide input so that your patient care plans function as
they are supposed to, effectively speaking to the needs of your patients, and efficiently controlling
documentation so it is not duplicative, is quickly indicated on forms and checklists when ever possible,
and is organized.
Question No. 12: You usually check a box every day that indicates you gave a supplemental feeding,
but today the patient is at the doctor’s office, so you couldn’t give the feeding. How should
you document this?
a. Check the box just as you routinely do.
b. Don’t check the box, and then indicate on the blank lines that the feeding was not given
because the patient was at the doctor’s.
c. Not checking the box is enough. No explanation is necessary.
d. All of these are appropriate.
Question No. 13: The goal says, “The patient will walk with assistance half the length of the hall
before needing rest.” All but one of the following is correct. Which is NOT correct?
a. This means that it will be only a nurse that will assist the patient because only nurses
need to follow the care plans.
b. Telling how well the patient walked is fulfilling the step of “evaluation of effectiveness.”
c. You might be able to chart this by checking a box that says, “Patient walked with
assistance.” And then just add how far he walked.
d. You need to indicate on some part of your charting that the patient did or did not walk
however far, and how it went.
LEGAL CONCERNS
There are multiple factors to consider when evaluating documentation from a legally protective point
of view, aside from our efforts to support the entire nursing process. Do write clearly, with correct spelling
and grammar. Ask yourself, if my charting were magnified to poster size and displayed in front of a jury,
could I read it? If you can't, the jury can't either, and your documentation time will have been wasted.
Make your sentences clear.
Be specific to time (no confusion to am or pm), and the timely order of events. Many facilities have
begun to use only black ink, because red, green and blue ball point does not reproduce well on our copy
machines, and some have started using military time to avoid confusion. Most healthcare workers do not
use enough indicators of time. In a court setting, lawyers often ask questions regarding time lags, i.e.,
"how many minutes was it between your actions and when you called the nurse?" Don't rely on your
memory. Write specific times as often as you can. Even estimates are better than no indication at all.
Use only your approved abbreviations for your facility It is legally unsafe to use an abbreviation not
listed on the facility's list of abbreviations, even if you think the entire world should know what the
abbreviation means.
Certainly there should be no blank lines, or spaces. We're very good about this in narrative notes,
but we tend to forget the concept applies to check lists, as well. Draw through the spaces, or put "n/a"
(not applicable).
Correctly label a late entry. Chart the time and date you are writing the entry, the reason you didn't
chart earlier (the chart was unavailable, or you overlooked this item, etc.), and the time and date you are
charting about. "7/25/08 1515hrs (late entry: failed to record earlier in day). On 7/25/08 at 1230 hrs, a 2
cm skin tear was discovered on the patient's left hand. The cause of the skin tear cannot be discovered.
Wound was cleansed, and nurse notified."
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Documenting the Process
An error on the chart happens to us all. We grab the wrong chart, or have another patient in mind
when we begin, or whatever. The old format was to cross one line through and write "error" and your
name or initials. However, the word "error'" may mean "clinical error" to the jurors. Some jurors have felt
the healthcare worker made an error with the patient, instead of with the chart. Thus, attorneys feel the
use of the word "error" is legally dangerous. They suggest we use "mistaken entry" instead, as a way to
clarify the nature of the error. Plus, we not only sign or initial, but we also need to put the date next to the
"mistaken entry". Make it easy, and have "M.E." listed as an approved abbreviation in your facility. Make
sure you take the necessary lines or spaces to clearly document your error. Resist the temptation to
include "M.E." and your initials on the side margins. This looks as though you came in two days before
the chart was procured by the lawyers, and edited your charting to make you case look better. Unless it
is a simple misspelled word, etc. use the following lines to write "M.E.", the reason for the error (e.g.
wrong chart), the date and time you are documenting the mistaken entry, and your name. Others will be
charting after you, and that will verify that you corrected the situation in a timely manner. If others have
charted in between the wrong entry and your need to enter the mistaken entry data, you can cross
through the error, and indicate in the margins, "M.E. See 9/15/08 2:30 pm. LG" Then, on the next
available line, chart, "9/15/08 2:30 pm: On 9/14/08 at 2:00pm a mistaken entry was made. This was the
wrong chart." Again, the lines will be filled following your entry, which will add support to even the brief
note written in the margin.
Never erase, cross out, scribble out, or change anything without this correct procedure. If you
wrote "Rt" and you mean "Lt", simply put a single line through it, date and initial it, and continue your note
appropriately. If you've forgotten something, but closed the note, DO NOT squeeze it in between the
lines or write it in the margins. Take the next existing open line, and write, "Addendum to note of (date
and time)".
Clearly document the patient's refusal to give information or to accept care. It is best if you use his
words. Chart and report all noncompliance. For example, if you told a patient to call for assistance
before getting up, and later found him on the floor, be sure you chart the previous instructions to the
patient, so any future jury knows you told him what to do. For example: "9:00 Assisted patient with
transfer to toilet. Patient dizzy and pivoting difficult. Instructed to ring the bathroom bell for assistance
when finished. 9:15 Found patient in chair. Stated she returned to chair unassisted. Reminded her to
call for assistance. Nodded assent." Although it is all we can do to remember to chart the things which
go wrong, in these type of circumstances, it will provide protection if we remember to chart these
incidents which did not end in mishap. If several hours, or several days later, the patient was found on
the floor, careful charting of noncompliance earlier would be a safeguard, and much more effective than
if you charted the noncompliance at the same time you are charting the incident.
Question No. 14: You just finished a long description of an event, when you noticed that this wasn’t
the correct patient’s form. What is the legally correct way to handle this?
a. Place one line through the incorrect note.
b. On the next line, indicate the time and date and write, “Mistaken entry at 2:30 on
9/15/2010. This was the wrong form.”
c. Sign your name.
d. All of these are the correct process.
Question No. 15: Which of these charting procedures is legally correct?
a. To label every entry with a date, time and your name or initials.
b. To leave blank lines or spaces.
c. To scribble out a mistake.
d. To squeeze information in the margins or between the lines.
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Documenting the Process
BIBLIOGRAPHY
Ashley, Ruthie, “Legal Counsel,” Critical Care Nursing, April 2005.
Beyea, Suzanne, “Implications of the 2004 National Patient Safety Goals,” AORN Journal, Nov. 2003.
Bott, Marjorie, “Care Planning Efficiency for Nursing Facilities,” Nursing Economics, March-April 2007.
Buchanan, Joan, “An Assessment Tool Translation Study,” Health Care Financing Review, Spring 2003.
Cruze, Guille, “Saying it isn’t so: How Documentation can Decrease Denials,” Healthcare Financial Management,
Feb. 2008.
Doyle, M, “Promoting Standardized Nursing Language Using An Electronic Medical Record System,” AORN
Journal, June 2006.
Harter, Joyce, “Put a Realistic Spin on Geriatric Assessment,” Nursing, December 2003.
Honea, Norissa, “Nursing Assessment and Interventions to Reduce Family Caregiver Strain and Burden,” Clinical
Journal of
Oncology Nursing, June 2008.
Huffman, Melinda, “Redefine Care Delivery,” Nursing Management, February 2004.
Lambert, Alan, “Red Flags in Medical Record Documentation,” Podiatry Management, February, 2004.
Lunney, Margaret, “The Need for International Nursing Diagnosis Research and a Theoretical Framework,”
International
Journal of Nursing Terminologies and Classifications, Jan-Mar, 2008.
Moorhead, Sue, “Diagnostic-Specific Outcomes and Nursing Effectiveness Research,” International Journal of
Nursing
Terminologies and Classifications, April-June, 2004.
“New Application Tracks Nursing Care, Results: Standardized Nonmenclatures Aid Benchmarking,” HealthCare
Benchmarks
and Quality Improvement, December 2003.
“Paper-Plagued to Paperless,” Health Management Technology, October, 2003.
Phillips, Michael, “Avoiding Medical Errors,” Journal of the American Dietetic Association, February 2004.
Szabo, C., “Interdisciplinary Care Planning,” International Journal of Nursing Terminologies and Classifications,
Oct-Dec., 2003.
“Good Documentation Enhances Care and Reduces Risk in Reimbursement,” Nursing Homes, May 2005.
Underwood, Reta, “Demystifying Documentation,” Nursing Homes, September 2004.
Williams, Linda, “Documentation Perils,” Nursing Homes, October 2005.
Wood, Debra, “Charting Software ‘Clicks’ with RNs,” Nursing Spectrum, Florida Ed, Feb. 26, 2007, pg. 10.
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Documenting the Process
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