DOCUMENTATION
As a Loss Prevention Technique
For Advanced Practice Nurses
1
Today’s Objectives
 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
protect your patient from harm and minimize
your liability exposure.
2
Legal Perspective on
Documentation
 Not documented, not done.
 Poorly documented, poorly done.
 Incorrectly documented, fraudulent.
3
Quality Documentation
Reflects Quality Care
 Structured documentation typically inspires
structured performance.
 Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
4
You Are Judged By How You
Document
A well-documented patient care record:
 Protects your patient
 Demonstrates that you are a competent nurse to:
–
Board of Nursing
–
Medicare
–
Other stakeholders and third parties
 Minimizes the potential of being named as a defendant in a
lawsuit
 Greatly assists with your defense if you are named in a
lawsuit
5
You Are Judged By How You
Document (continued)
A well-documented patient care record:
 Minimizes the potential of a court appearance if
you ARE named in a suit
 Aids in development of successful defense
 Helps against licensure actions
 Reduces the chance of criminal charges
6
The Patient Care Record
Is a Legal Document
 Under state laws, the patient care record is the property
of the health care provider
 A patient is entitled to request and receive a copy of the
record under the laws of most states
 The record must reflect accurate and timely information
 The patient care record documents the care provided.
 You may not alter, remove, copy, or destroy a medical
record
7
Additions and Corrections:
Handwritten Documentation
 If you must make a late addition or correction to a
patient’s care record, follow these guidelines or
your healthcare facility’s protocol:
– Mark with one line through the item
– Make the notation / correction and explain why you did so
– Date and sign the corrected documentation
8
Additions and Corrections:
Electronic Documentation
 Obtain assistance from EMR experts in establishing policies
and procedures
 Establish polices and procedures for standardized action for
additions and/or clarifications in EMR
 Educate staff to approved EMR policies and procedures
 Regularly audit EMRs for compliance with policies and
procedures
 Remind staff that all entries are automatically dated and timed to
prevent contradictory dates and times
9
Basis for Reimbursement
Your documentation will
influence how you and your
employer are reimbursed for
services rendered and may
minimize financial loss.
10
Billing
Include the following documentation to support
appropriate billing for services rendered:
 the actual provider
 the service or services provided and
 the diagnosis
These facts should already be in the patient’s care
record.
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Billing and Reimbursement
 The billing and reimbursement of your facility is your
responsibility, and you should take ownership for the entire
process
 Be familiar with your health plan participation contracts,
and review any changes and additions on a periodic basis
 Internally audit your facility’s documentation to determine if
documentation consistently supports the code billed
 Monthly, monitor a sample of your collections against your
charges
 Validate that documentation has supported the appropriate
coding and billing by monitoring collections
12
Medicare Fraud and Abuse
It is Illegal to:
 Submit bills for services not rendered
 Upcode a service
 Unbundle services
 Solicit, offer, or receive a bribe or kickback
 Bill “non-covered” services as covered services
 Fail to comply with Medicare marketing rules
Medicare Fraud and Abuse.
Medicare Learning Network. CMS.
February 2010
13
Medicare Fraud and Abuse
Know and understand:
 Anti-Kickback Statute
 Physician Self-Referral
Prohibition Statute
Medicare Fraud and Abuse. Medicare Learning
Network. CMS. February 2010
14
Medicare Fraud and Abuse
Avoid a Lawsuit
 Stay current with CMS billing rules, and follow
them consistently
 Be aware of common conditions that lead to
malpractice claims
 Understand your facility’s billing and
reimbursement system
 Avoid common prescribing errors
15
Considerations for
Quality Documentation
Do Enter:
 Contemporaneous documentation
 Accurate documentation
Do Not Enter:
 Fraudulent documentation
 Inappropriate documentation
16
Documentation Dos
 Check that you have the correct medical record before you begin
writing.
 Make sure your documentation reflects the clinical decision
making process.
 Write legibly if using handwritten documentation.
 Contemporaneously record patient care at the time you provide it.
 Record the time you gave a medication, the dose, administration
route, and the patient's response.
 Record precautions or preventive measures used, such as placing
the call-bell in the patient’s reach.
 Document often enough to tell the whole story.
17
Documentation Dos (continued)
 Record each phone call to a physician or other member of the
patient’s treatment team, including the exact time, message, and
response.
 Record a patient's refusal to allow a treatment or take a
medication, obtain the patient’s written refusal, and be sure to
report this to your manager and the patient's physician.
Document that the patient was informed of the risks of refusing
treatment.
 If you remember an important point after you've completed your
documentation, record the information with a notation that it's a
"late entry." Include the date and time of the late entry. Late
entries should be limited to facts that are essential to the
patient’s care and treatment.
 Document review of systems and relevant findings.
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Documentation Dos (continued)
 Include differential diagnosis
Example:
• “c/o epigastric pain for 3 months,
differential diagnosis includes but not
limited to gastritis, peptic ulcer disease,
pancreatitis, and cholecystitis”
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Documentation Don’ts
 Don't Record a symptom, such as "c/o pain," without also
recording what you did about it
 Don't alter a patient's record--this is a criminal offense
 Don't use shorthand or abbreviations unless they are included in
the organization’s approved abbreviation list.
 Don't write imprecise descriptions, such as "bed soaked" or "a
large amount"
 Don't give excuses, such as "Medication not given because not
available"
 Don't record what someone else said, heard, felt, or smelled
unless the information is critical
 Don't record care ahead of time--something may happen and
you may be unable to actually give the care you've recorded
20
10 Documentation Strategies
1. Do not erase, use “white out”, or cross out an error
with more than one line
2. Record only the patient’s statements, clinical facts,
observed behavior, and health services rendered
3. Do not criticize other health care providers or
document your personal opinions
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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10 Documentation Strategies
5. Do not leave blank spaces
6. Record all entries legibly and in ink
7. Avoid generalized phrases such as "bed soaked"
or "a large amount"
8. If an order is questioned, document that
clarification was sought, the order discussed and
resulting resolution
22
10 Documentation Strategies
9. Document only your own observations and
patient services rendered.
10. Do not permit any visiting relative or other
third-party access to the patient care record
unless they have been granted legal authority
to do so.
23
Communication Challenges
Attributes:
 Factual
 Accurate
 Current
 Confidential
24
Reporting Challenges
APNs must communicate information about patients to
nurses and other members of the patient’s health
care team.
 Oral report, video or audio taping
 Documentation / written report
25
Documentation Techniques
26
Documentation Techniques
SOAP
S: Subjective
O: Objective
A: Assessment
P: Plan of Care
27
SOAP
Strengths
Weaknesses
 Address specific problems
 Can be inflexible
 Organized
 Routine care can be difficult
to document
 Problem List
 Notes show continuity of
care and evaluation and
resolution of problems
 Time-consuming
 Difficult to decide where to
place data
 Eliminates nonessential data
28
Documentation Techniques
SOAP (SOOOAAP)
 Expanded method that includes additional
risk-reduction techniques
 Opinion, Options, Advice, Agreed Plan
29
Documentation Techniques
Narrative
 Chronological account of events in a
free-form, sentence-based structure
 May include columns or sections to
organize information
30
Narrative
Strengths
Weaknesses
 Simplified method
 Lack of guidance
 Control
 Freeform can produce notes
that are:
 Chronological
 Adaptable
 Easy to teach or learn
– Fragmented
– Rambling
– Inconsistent between authors
– Non-informative
31
Documentation Techniques
Electronic Documentation
 Increasingly common
 Use of technology to manage patient
medical records
 Variety of hardware and formats
 Allow patient medical records to be
created, updated, stored, and retrieved
via computer
32
Electronic Documentation
Strengths
Weaknesses
 Legible
 Facility must make major
cash investment
 Prompting
 Changes tracked
 Modifiable system
 Consistent
 Easy to find
 Training
 Possibility of software or
hardware crash
 Major psychological change
 Inaccuracies
 Entries are time and date
stamped
33
Documentation Techniques
Open Charting
 Also referred to as “Shared
Medical Records
 Currently employed by a number
of hospitals
 Method devised to encourage a
patient to be involved in his or her
own care, to review the notes
made by their healthcare
providers
34
Open Charting
Strengths
 Encourages patients to review their
own patient care record
 Promotes meticulous documentation
by healthcare providers
 Fosters patient inclusion in the
healthcare delivery process
Weaknesses
 Requires significant time
 May raise patient queries regarding the
healthcare delivered
35
HIPAA and Documentation
 Security Rule and Privacy Rule
 The Security Rule Documentation standard has
three implementation specifications.
–
Time Limit (Required)
–
Availability (Required)
–
Updates (Required)
36
HIPAA and Documentation
 HIPAA requires covered entities to meet
documentation requirements
 Be aware of and report any suspected security
breaches
 Take steps to prevent patient health
information from falling into the wrong hands
or being inadvertently altered or destroyed
37
Effective Risk
Management Strategies
 Know and comply with State Scope of Practice
 Comply with Nurse Practice Act
 Practice Competent Nursing
 Comply with policies, procedures and regulatory
requirements
 Practice appropriate billing and coding methods
 Seek additional educational opportunities
 Follow ICD-9 CMS guidelines for documentation
 Follow appropriate incident reporting protocol
38
Incident Reporting
Losses can be reduced by a timely, prudent,
and compassionate response to an incident.
 Report any incident to your risk manager.
 Report an incident to your insurance provider – if
you have your own policy.
39
Learn Your
Organization’s Guidelines
Examples of
Reportable Incidents
– Treatment-related injuries
– Patient falls
– Missed/incorrect diagnosis
– Medication errors
– Employee exposures
– Equipment failure
– Facility-acquired pressure
sores
– Complaint by patient,
family, visitor
40
BE ALERT!
Report Unusual Occurrences
 Document ONLY the facts
 Report immediately, i.e., within 24 hours
 Do not speculate
 Do not draw conclusions
 Do not document impressions
41
Quality Monitoring
Participate in investigations and analysis
of the cause of the incident
Maintain confidentiality of all information
42
Case Study
Failure to Assess Patient – 78 year old female
 Patient
– 78 year-old female nursing
home resident
– Hypertension, chronic
anemia, chronic renal
failure, congestive heart
failure, morbid obesity
– She was on the anitcoagulant Coumadin
because of atrial fibrillation
 Defendant
– Onsite NP working for outside
healthcare facility via contract
with nursing home
– Responsible to answer calls for
healthcare facility and return
emergent pager calls
– Responsible for making visits to
nursing facility as needed
43
Case Study
Failure to Assess Resident – 78 year old female
 Day 1
– Attending MD (also president of the facility) ordered that the
resident be started on Bactrim for bladder infection
– Staff questioned order because of potential for adverse effect of
combining Bactrim and Coumadin
– Resident also took daily doses of ibuprofin
 Day 2
– Lab tests showed no bladder infection
– Bactrim was not discontinued
 Day 6
– Lab tests showed that resident’s bleeding time had increased – at
risk of bleeding from Coumadin
44
Case Study
Failure to Assess Resident - 78 year old female
 Day 8
– Resident bleeding from gastrointestinal tract
– NP gave orders to stop Coumadin for 2 days and recheck blood tests
on Day 11
 Day 10
– Alleged that the NP was advised by nursing home staff of blood clots
in resident’s stool
– NP faxed her on-call report to the medical director after each call
from the nursing home
– NP did not keep copies of the reports or of her notes made during
calls
– Medical director denied receiving the reports
45
Case Study
Failure to Assess Resident - 78 year old female
 Days 9-11
– Resident continued to bleed
– NP, attending and medical director were notified but took no action
– Nursing staff notes reflect that the resident was dizzy and
nauseated
 Day 11
– Resident found dead in bed
– Bled to death from gastrointestinal hemorrhage
46
Case Study
Failure to Assess Resident - 78 year old female
 Allegations Against NP
–
Failure to evaluate, monitor, and treat the resident’s
severe anemia and bleeding
–
Failure to timely contact the medical director about the
patient’s bleeding
–
Exceeding the scope of practice by making medical
decisions about the patient’s bleeding
47
Case Study
Failure to Assess Resident - 78 year old female
 The Defense Argument
– NP was within the standard of
care for taking a telephone triage
call by holding the Coumadin
and ordering a follow-up INR lab
level.
 The Plaintiff Argument
– NP should have obtained vital
signs, medications, current
problem list, past medical
history and labs.
– Responsibility of the NP to
obtain the information she
needed to make an
appropriate assessment and
not wait for it to be offered to
her.
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Case Study
Failure to Assess Resident - 78 year old female
 The Resolution
– Took 2 ½ Years to settle
– Settled at mediation for $450,000 plus additional $181,225 in legal
expenses
– Healthcare facility and nursing home also settled for separate
amounts.
Total incurred expense for NP: $631,225
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Case Study
Failure to Assess Resident - 78 year old female
 Risk Management Comments
– Unclear accountability and communication channels
– Nursing concerns were not heeded
– Role of pharmacist is unclear
– Defendant did not document her actions
– Defendant did not physically assess the resident despite evidence
of acute G.I. bleed
– Oversight of the resident was not maintained by any individual
practitioner
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Case Study
Failure to Assess Resident - 78 year old female
 Risk Management Recommendations
– Clearly define role of scope of practice of APN
– All communication is to be documented in a pre-defined,
consistent, confidential manner
– Each resident must have an identified attending physician
– On-call practitioners must physically asses deteriorating
resident when physician unavailable
– Do not fax information without providing original documentation
in the resident’s health record
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Documentation
Examples
52
Documentation: An Example
– Abdominal pain listed on problem list 1/2010,
related to acute gastroenteritis-resolved
– Patient admitted to hospital 4/2010 for
abdominal pain, radiologic evaluation
performed- CT abdomen shows abdominal aortic
aneurysm
– The problem list still maintains the problem
abdominal pain from 1/2010. Could appear
abdominal pain was actually from AAA in 1/2010
 Could be perceived as delay in diagnosis
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Sample Medical Record
Date: May 7, 2010
Patient Name: Tom Jones
Chief Complaint: C/o 2 day history of rectal bleeding.
HPI: 56 yr old male c/o rct bleeding for 2 days. States he feels fine. (+) family hx colon
cancer.
Active Problems
Mild-Moderate Abdominal Pain (789.00)
Family history of Diabetes Mellitus (V18.0)
Family history of Essential Hypertension
Hypertension 25 Jan 2008 (401.9)
Hypothyroidism (244.9)
Mammogram Screening; Bilateral (V76.12)
PMH
Arthritis (V13.4)
Asthma (493.90)
No Birth History; Term BW, 7-10, C/S, jd, photorx
Diabetic Autonomic Neuropathy Type I (250.61)
No Exercising Regularly
Hypertension (401.9)
Red Blood In Bowel Movement (Hematochezia) Resolved (578.1)
Reported Prior Thyroid Disease.eg
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PSH
Bone Grafting With Microvascular Anastomosis Iliac Crest
Colonoscopy (Fiberoptic); 2005-tics, ih, polp-3 yrs
Hysterectomy (V45.77)
No Surgery
Surgery Of Male Genitalia Vasectomy (V25.2)
Tonsillectomy.eg
Current Meds
Prilosec 10 MG Capsule Delayed Release;TAKE 1 CAPSULE DAILY; RPT
Klonopin 2 MG Tablet;TAKE 1 TABLET TWICE DAILY AS NEEDED.; RPT
CombiPatch 0.05-0.14 MG/DAY Patch Biweekly;; RPT
Staticin SOLN;APPLY AS DIRECTED.; RPT
Statins Support MISC;TAKE KIT; RPT
Statins Depletion MISC;TAKE KIT; RPT.eg
Allergies
Aleve TABS
Penicillin G Pot in Dextrose SOLN
Sulfa Drugs.eg
55
Family Hx
No Family history
Family history of
No Family history
Family history of
Family history of
Family history of
healthy
Family history of
Family history of
No Family history
Family history of
Family history of
Family history of
Family history of
Family history of
No Family history
No Family history
No Family history
No Family history
Family history of
No Family history
of Coronary Artery Disease
Diabetes Mellitus
of Essential Hypertension
Family Health Status
Family Health Status Brother 1; 0
Family Health Status Brother 1; x2x1-deceased car accidentx2
Family Health Status Father; deceased colon cancer
Family Health Status Number Of Children; 2 boys twins
of Family Health Status Of Mother - Alive
Family Health Status Sister 1; x3
Family Health Status Sister 1
Hyperlipidemia; Father
Hypertension
Reported Family History Ischemic Heart Disease Before Age 50
of Malignant Carcinoma Of The Breast; mother
of Malignant Neoplasm Of The Large Intestine
of Reported A Family History Of Alcoholism
of Reported A Family History Of Congenital Heart Disease
Reported Family History Ischemic Heart Disease Before Age 50
of Thyroid Disorder
56
Personal Hx
Alcohol; Occasionally
No Behavioral History
Being A Social Drinker
Caffeine Use
Cigars (___ A Day) (V15.82)
Currently In School
Daily Coffee Consumption (___ Cups/Day); 3 cups daily
Daily Cola Consumption (___ Cans/Day); 1 daily
No Daily Tea Consumption (___ Cups/Day)
Drinking In Moderation (2 Drinks / Day Or Fewer)
No Drug Use
Exercise Habits
No Exercising Regularly
Marital History - Currently Married
Never Smoked
Occupation:; Self employed
No Secondhand Tobacco Smoke In Home
No Smoking Cigarettes
No Smoking Cigarettes For ____ Pack-years
social history reviewed; lives w/ mom, dad, 2 yr old brother joe, 1 dog , no
smokers
No Tobacco Use
57
Physical Exam
Abdomen:
Visual Inspection: ° Abdomen was normal on visual inspection.
Auscultation: ° Bowel sounds were normal.
Palpation: ° Abdomen was soft. ° No abdominal tenderness.
° No mass was palpated in the abdomen.
Hepatic Findings: ° Liver was normal to palpation.
Splenic Findings: ° Spleen was normal to palpation.eg
Plan
Notify office if symptoms worsen.
Electronic Signature: Sue Smith, NP
Date: May 14, 2010 20:00
58
Inadequate Documentation
1. HPI is not complete. Documentation contains
abbreviation which is not approved: rct
2. Family History: Contradiction- states there is a
family history of colon cancer with father –next line
below states no family history
3. Plan: Omits quality of signs and symptoms follow-up
and follow-up instructions to seek emergency care if
it is during a weekend
4. PE: Omits rectal exam
5. Time stamp of electronic signature is 1 week after
original date of service
59
Additional Resources
 CMS Website (cms.gov)
 Office of Inspector General (2010 Work Summary)
(oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf)
 ICD-9 (cdc.gov/nchs/icd.htm)
 The American Association of Nurse Attorneys
(TAANA) (taana.org)
 California Health Advocates (cahealthadvocates.org)
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Documentation Bloopers
 “Patient had waffles for breakfast
and anorexia for lunch.”
 “The patient refused an autopsy.”
 “She is numb from her toes down.”
 “The patient has no previous history of
suicides.”
 “While in ER, she was examined, xrated, and sent home.”
 “Patient has left white blood cells at
another hospital.”
 “The skin was moist and dry.”
 “On the second day, the knee was
better, and on the third day it
disappeared.”
 “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.”
 “The patient has been depressed since
she began seeing me in 1993.”
 “Discharge status: Alive but without
permission.”
 “Healthy appearing decrepit 69-year
old male, mentally alert but forgetful.”
 “Patient has two teenage children, but
no other abnormalities.”
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