DOCUMENTATION
As a Loss Prevention
Technique
Today’s Objective
» Increase awareness of documentation risks,
specifically targeting exposure to negligence and
malpractice claims.
» 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 help protect your patient from
harm and minimize your liability exposure.
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Legal Perspective
on Documentation
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Not documented, not done.
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Poorly documented, poorly done.
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Incorrectly documented, fraudulent.
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Quality Documentation
is Quality Care
• Structured writing typically inspires
structured performance.
• Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
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You are what you document
A well-documented patient care
record:
 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.
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The Patient Care Record
is a Legal Document.
• Under state laws, the patient care record is the
property of the health care provider.
• Patient is entitled to a copy of the record under
the laws of most states.
• The record must reflect accurate and
contemporaneous information.
• The patient care record documents the care
provided.
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Basis for
Reimbursement
Your documentation may
influence how you and your
employer are reimbursed for
services rendered and
minimize financial loss.
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Considerations for
Quality Documentation
Contemporaneous documentation
Accurate documentation
Fraudulent documentation
Inappropriate documentation
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Documentation as a Loss
Prevention Technique
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Documentation Dos and Don’ts:
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10 Risk Management Strategies
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Risk Management Strategy 1
Do not erase.
Do not use “white out”.
Do not cross out an error with
more than one line.
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Risk Management Strategy 2
Record only the facts.
Document only observed
behavior.
Document healthcare services
rendered.
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Risk Management Strategy 3
Do not write critical comments.
Do not document your
opinions.
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Risk Management Strategy 4
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)
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Risk Management Strategy 5
Do not leave blank spaces.
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Risk Management Strategy 6
Record all entries legibly
and in ink.
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Risk Management Strategy 7
Avoid generalized phrases
such as "bed soaked" or "a large
amount."
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Risk Management Strategy 8
If an order is questioned,
document that clarification
was sought and discussed.
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Risk Management Strategy 9
Document only your own
observations and patient
services rendered.
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Risk Management Strategy 10
Do not permit any visiting
relative or other third-party
access to the patient care
record.
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Communication Challenges
Attributes:
» Factual
» Accurate
» Current
» Confidential
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Reporting Challenges
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.
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Documentation Techniques
Strengths and Weaknesses
Documentation Methods
• Charting by Exception
• FOCUS
• Narrative
• SOAP
• Electronic
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Documentation Methods
• Charting by Exception
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Documentation Methods
• FOCUS
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Documentation Methods
• Narrative
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Documentation Methods
• SOAP
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Documentation Methods
• SOAP (SOOOAAP)
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Documentation Methods
• Electronic
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Effective Risk
Management Strategies
• Comply with Nurse Practice Act
• Practice Competent Nursing
• Comply with Policies and Procedures
• Follow Appropriate Incident Reporting
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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
• Patient falls
• Treatment-related injuries
• Medication errors
• Missed/incorrect diagnosis
• Equipment failure
• Employee exposures
• Complaint by patient,
family, visitor
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BE ALERT!
Report unusual occurrences
Document ONLY the facts
•
Report immediately, i.e., within 24 hours.
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Do not speculate.
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Do not draw conclusions.
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Do not document impressions.
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QUALITY MONITORING
• Participate in investigations.
• Maintain confidentiality of all information.
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Open Charting
• Encourages patients to review
their own patient care record
 Promotes meticulous
documentation by healthcare
providers
 Fosters patient inclusion in the
healthcare delivery process
Requires significant time
May raise patient queries
regarding the healthcare
delivered
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Documentation
Examples
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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.”
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THE END