Proper documentation is one of the most important parts of nursing in long term care facilities. A resident’s record is the place where all of their important medical information resides. It lets nurses and caregivers know what medications the resident is taking, their dietary restrictions, their diagnoses, and other important medical information.
Proper nursing documentation also has an effect on the amount of reimbursement the facility receives from Medicare or Medicaid for each patient. If something is not documented properly or is miscategorized, there could be a significant discrepancy in the amount of reimbursement the facility receives for that resident.
The key to proper documentation is to remember that residents are people with very human needs. “The fundamentals of nursing have a lot to do with people,” said Rosale Lobo, assistant professor of Nursing and Health Policy at The University of Bridgeport. “When we teach people how to be nurses, we don’t go right into disease processes; we teach them about people first.” She described how this is moreso the case in long term care settings, where nurses are “pretty much everything,” making this education about people the foundation upon which learning about disease and illness is built.
Over the course of thirty years, Lobo learned about documentation and connecting with residents as a direct care nurse, professor of nursing documentation, and legal nurse consultant. She shared her insight and tips for adhering to the legal standards of documentation in a recent appearance on the LTC Heroes podcast:
An Overview of Documentation in Nursing Care
Documentation in nursing involves the practice of keeping detailed records of the nursing care that is provided to residents in long term healthcare facilities. Nurses and other caregivers must carefully and appropriately document all care provided in order to meet legal and professional requirements. Nursing documentation is a vital part of safe and ethical nursing practices.
The practice of nursing documentation and record-keeping was historically done through a paper Kardex system in which nurses and other caregivers would take time to manually fill out patient charts every day or multiple times per day. Paper documentation could include medical records, details of the care provided each day, different patient safety requirements, labs, demographics, physician notes, and other very basic pieces of information that a nurse or doctor would need to know.
With advances in technology and healthcare sciences, there are many types of nursing documentation and new solutions such as electronic health records EHR were introduced as a way to reduce the amount of documentation error and increase communication among nursing staff and other healthcare providers. The switch to an electronic system was a great first step to improve the quality of documentation by eliminating things like the concern for a healthcare provider to write legibly. An electronic Kardex, meanwhile, is capable of notifying nurses with pop-ups about the most pressing matters and activities of daily living (ADLs).
The Importance of Documentation in Nursing
Accurate documentation of resident care is a vital part of the nursing process and should be well understood by each member of the nursing care staff that comes into contact with a long term care resident. According to Medcom—an education provider for healthcare professionals—improper documentation or failure to include pertinent information can lead to poor patient outcomes as well as liability issues for the facility and staff who treat the resident. Thus, the importance of documentation in nursing cannot be overemphasized.
There are strict policies and procedures in place for what needs to be included in the nursing documentation of a patient’s record and how it should be recorded in order to receive the appropriate patient care reimbursement amounts, as well as to avoid any adverse events that may occur as a result of inaccurate documentation. Not only is patient safety and standard of care a main concern for documentation in nursing, but there is a huge liability issue that can occur when care documentation is inaccurate or if the documentation reflects unclear information, which could result in some serious legal issues. You can use the nursing documentation errors below as guidelines for documentation in nursing to ensure your facility maximizes its profitability.
The Implications of Missing Documentation
When there is no documentation to provide proof that proper care or examinations were provided, there is a lack of legal proof that the nursing staff did all they were obligated to do in order to care for the resident. This could result in a substantial lawsuit for the hospital or care facility.
In one case, Susan Meek. V. Southern Baptist Hospital of Florida, a patient was admitted to the hospital for a hysterectomy. She developed bleeding after surgery and was admitted for uterine artery embolization (UAE) in order to stop the bleeding. The attending physician required the nursing team to perform frequent leg examinations in order to minimize the risk of diminished blood flow and nerve injury, but the patient claimed the exams were not performed and the patient sustained nerve damage.
A lawsuit was brought to a court of law, and since the examinations were not properly documented, there was no way to prove that the nurses did, in fact, perform the examinations. The case resulted in a $1.5 million verdict. As you can see, this case was not just about whether or not the standard of nursing provided was accurate but whether the hospital staff gave complete documentation of the patient’s treatment plan.
The Types of Nursing Documentation for Patient and Resident Care
There are a multitude of data points that go into the practice of creating complete and accurate nursing documentation for patients and residents in hospitals and long term facilities. This means more than just medical records; all vital information that can help to improve and document a patient’s or resident’s care must be documented for care providers to access.
This information was previously documented on paper. Now they can be documented using electronic health records, which increase efficiency and reduce errors. The Wisconsin Technical College System categories legal documentation into the following formats:
- Charting by Exception (CBE): This consists of a list of normal findings that a doctor or nurse may encounter as well as brief progress notes on information findings that can be shared with team members.
- Focused DAR Notes: Data, Action, Response (DAR) progress notes focus on one patient problem for efficacy in documenting.
- Narrative Notes: These include the practice of providing a summary of nursing quality activities that occur throughout the nurses’ shift.
- SOAPIE Progress Notes: SOAPIE is a mnemonic that stands for Subjective, Objective, Assessment, Plan, Interventions, Evaluation. These notes are categorized and written by nurses and other professional caregivers on the health care team.
- Patient Discharge Summaries: Patient Discharge Summaries provide a summary of the patient’s discharge details as well as clear written instructions for the resident and home caregiver for medications, diet, follow-up appointments, etc.
- Minimum Data Set (MDS) Charting: This refers to the information that is provided for private insurance, Medicare, and Medicaid reimbursements. Inaccurate MDS charting is another case where a lack of documentation with high-quality details can result in a substantial financial loss for the long term care facility.
Good documentation, as identified by Medcom, is:
- Timely (current)
- Compliant with healthcare laws and facility standards
The Challenges of Nursing Documentation
One of the biggest obstacles to good nursing practice is the lack of understanding of what qualifies as proper or adequate documentation. In a study of government-owned hospitals in Ethiopia, it was found that more than half of the 317 nurses who participated were not properly documenting their nursing care. The results of the study were troubling, as they indicated that nursing records were often incomplete, lacked accuracy, and were not of professional quality. The study indicated that challenges surrounding documentation included:
- Shortage of nursing care staff
- Inadequate knowledge concerning the importance of nursing documentation
- A high patient load for each nurse
- Lack of high-quality in-service training in the documentation and nursing process
- Lack of support from nursing leadership.
The Disconnect Between Patient or Resident Care and Documentation
- Environmental conditions
- Lack of critical thinking
- Infrastructural problems
- Lack of communication
It is important that nurses are aware of what needs to be kept in mind. When discussing the errors in quality nursing documentation, she said that, “The biggest obstacles are the fragmentation in the [knowledge of] charting because when you don’t understand the bigger picture, then you have no idea how much or how little the entries you make contributes to the care and the outcome of the patient.”
While nurses receive training on other matters related to care, they are never formally taught how to keep track of patient and resident information. “The understanding of documentation is poor because no one ever taught nurses how to document,” Lobo said.
Further, there is a disconnect between software implementation and the actual nursing process. Additionally, there is a disconnect between nursing implementation and interpretation of the record, which makes for a less than seamless transition from start to finish of the process. What Rosalie has seen over her years in the health sciences industry is that there are nurses who work in nurse informatics or software development, but they don’t actually work directly with the patient or resident at the bedside.
8 Common Documentation Errors
Fortunately, nursing documentation can be improved drastically by simply paying closer attention to important details. Here are a number of common errors in the process of nursing documentation that can be easily resolved and will lead to more accurate charting and improved data:
1. Writing Illegibly
For facilities that are still using a paper documentation system, sloppy handwriting or inaccurate use of acronyms can cause confusion and communication issues regarding documentation, which can negatively impact the health of the patient or resident; if the nursing staff can’t read the care instructions that someone else wrote down, the health of the patient or resident could be put at risk.
Something as seemingly simple as illegible documentation of medication administration could be catastrophic or even result in the death of a resident. Thus, medical documentation should be clear, concise, accurate, legible, and complete.
2. Not Properly Dating or Signing Entries
Every member of the care team should get into the practice of providing the date, time, and name that correspond with each record. Some EHRs will enter this information automatically, but otherwise, this is a nursing practice that should be ingrained into every step of the charting process.
3. Leaving Blank Forms or Incomplete Information
Omitting data or leaving forms on the record blank can leave other members of the care staff wondering if care was delivered and not recorded, or if it was delivered at all. Nurses should find a consistent way to indicate blanks or fields that are not applicable to the resident.
4. Copying and Pasting the Wrong Information
Taking shortcuts is one of Medcom’s don’ts for nursing documentation. Rather than copy and paste from medical records, take the time to write out notes each time. This will ensure that no outdated information gets recorded, and provides an extra checkpoint for nurses to take note of changes in resident care requirements.
5. Adding Late Entries
It is important for staff to get into the practice of adding information right away. Nurses have so many things going on at once, and it can be easy for the details of an assessment to slip one’s mind very quickly. Failing to record data in a timely manner can lead to an incomplete medical record that could negatively impact the patient or resident. Nurses should pay extra attention to ensure they are not providing a late entry that could be a detriment to patient care. An electronic Kardex is an excellent way to stay alert and receive notifications for tasks that have priority.
6. Entering Subjective Data
Using subjective, non-clinical terms such as “grumpy” or “irritating” to describe a resident does not give an accurate assessment of the resident’s medical state. Rather, these terms tend to reveal more about the nurse’s interpretation of the patient’s mood. In cases where the patient or resident has a bad outcome, subjective terms rather than proper clinical language on a chart may call into question the quality of care the nurse provided.
Incident reports, too, should be factual and free of the staff’s hypotheses about what caused a particular incident. Yes, if the cause of a fall, for instance, can be determined, that should absolutely be included in the incident report so as to avoid similar such incidents in the future.
7. Failing to Document New Symptoms or Updated Conditions
Appropriate nursing practice is to immediately document any new condition that another caregiver may need to know. This data should include the time of onset, the actions taken by the staff, and the patient’s or resident’s response. It should also include any changes in conditions that the resident was diagnosed with in the hospital, as well as any new abrasions, cuts, falls, bumps, changes in temperature, changes in diet or digestion, or changes in vital signs.
8. Entering Data Into the Wrong Chart
This error can happen easily, especially with electronic records. In order to avoid this problem, staff should get into the practice of immediately checking the name on the chart with the name of the patient or resident in the room. It is helpful for a nurse to always address the patient or resident by name to ensure they have the right electronic record or chart in front of them before entering information. As Lobo said during her appearance on LTC Heroes, the “bells and whistles” of EHR are not necessarily helpful. “We still have to be able to put into charting what we want to get charted,” she said.
5 Tips for Improving Nursing Documentation
With the right mentality and preparation, nursing documentation will only continue to improve. MDS nurses must think like investigators. And CNAs and the rest of the staff must be willing to learn to take advantage of the most recent developments in technology.
1. Think Like a Jury
It is easy to forget that resident medical records are legally binding documents. That is why nursing home staff will benefit from treating documentation like the gathering of evidence before going to trial. Alan Horowitz, previously a litigator for the Centers of Medicare and Medicaid and other healthcare organizations, provided advice on how to think like a jury when documenting resident information.
Chart the facts accurately and completely
According to federal regulations, nursing homes “must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized.”
It is, then, important that documentation is:
- Thorough: Include all the details about time, place, and the measures taken. Horowitz gives the example of a patient who complained of chest pain. If the nurse simply writes that this individual “complained of chest pain at 10:30 a.m,” that will not be sufficient if the patient later dies and the facility is taken to trial. This is because, the staff will not be able to establish what was done after the complaint, who was contacted, when they were contacted, or what the patient’s vital signs were. In short, the attorney can point out that the nurses did not follow the standard procedures of documentation. Horowitz then provides an example of what thorough documentation would look like in this case:
Mr. Smith complained of dull chest pain that began about 10 minutes ago. Patient denies pain in arms, jaw or elsewhere. Vital signs taken, B/P: 120/64. RR: 18 and unlabored, heart rate, 72, regular. Dr. Jones notified at 10:42 am. No new orders given. Will monitor and continue to report any changes to nursing supervisor.
Another element of being thorough is documenting cases of resident nonadherence, or, the reasons why a resident refused treatment or medication, the alternatives that were presented to him or her, and whether or not the risks associated with rejecting the nursing home’s recommendations were explained to the resident.
Lastly, discharge planning and the degree to which this was made in consultation with the resident and his or family must be documented. The next steps and the people who will then be providing care must be established in writing as well.
- Timely: Late entries cannot become commonplace, as they will raise eyebrows for state regulators and affect reimbursement. If late entries cannot be avoided in exceptional cases, then they should be labeled as such (“late entry”).
- Personal: Do not take lightly what residents say. Write everything down. That includes phone conversations, which may be called into question as well.
- Clear: The language you use must be explicit, and if a mistake is made, that should be evident as well; do not use correction fluid (like Wite-Out). Rather, draw a line through the wrong word and write “mistaken entry,” the date, and your initials next to it.
- In accordance with protocols: Not only should the person documenting this information observe the guidelines above, but they must be qualified to do so. Thus, only the appropriate authorities should be allowed to document. Also make sure to leave blank lines between entries so that they are not confused for one another. Hopefully this doesn’t need to be said, but it is absolutely crucial that you do not put your facility at risk by relying on memory instead of investigating, falsify medical information (a federal offense), or destroy any part of a medical record.
Make sure that your documentation is in accordance with your facility’s particular charting policies. Horowitz writes that many facilities are adopting SBAR (situation, background, assessment, recommendation) forms, which are filled out before a physician, nurse practitioner, or physician assistant is contacted. A nursing team can use these to share information about signs and symptoms that will help them avoid hospitalization.
2. Embrace Advancements in Nursing Technology
Medical software companies are constantly updating electronic healthcare records and integrating them with other systems. The real challenge is training staff on how to use EHRs. This can be costly, especially with the high turnover rates of nurses in long term care. Fortunately, EHR training recently became available online absolutely free of charge. The more knowledgeable and experienced that a nursing staff is about EHR, the better they will take advantage of EHR. One study found that nurses with experience of more than one year entered nursing records over two times more during their working hours than did less experienced nurses.
Access to all-in-one electronic health record systems creates an abundance of time for staff in long term care facilities. Nurses no longer have to spend hours at the beginning of their shift updating paper records for each resident they serve. That information is now available in real time and easily accessible through point of care systems that are mobile friendly and can be updated as nurses are talking with or providing care to their residents.
The next three items are among the Dos recommended by Medcom.
3. Check, Check, and Check Again
It may seem obvious, but you will want to ensure that you have the right resident name on the chart to make sure you are recording data for the correct person. While efficiencies in electronic nursing documentation make it easy to toggle between patient charts, it can also be easy to accidentally enter information for the wrong resident. So remember to slow down and reread your entries before moving on.
4. Do Not Procrastinate
Enter resident data in a timely manner. When changes are needed, be sure to record them right away. A Point of Care system allows staff to easily input resident data on tablets or other mobile electronic devices that can easily be carried from room to room. An electronic Kardex will keep nurses alert as to the most urgent matters with pop-ups that must be acknowledge.
5. Spell It Out
Use medical terms and plenty of detail when describing the resident’s condition. You must also use the resident’s own words or describe non-verbal cues in order to give an accurate and specific picture of the resident’s condition.
Nursing documentation is not something to be taken lightly. You must ensure that your staff is getting everything, articulating it clearly and accurately, and remaining objective. Otherwise, your facility may not be in compliance with federal regulations and state laws, which will result in deficiencies. The penalties for deficiencies vary, but sanctions and even forced closure of your facility are possibilities. In some extreme cases—like falsifying medical records by claiming that medication was administered when it was not—the responsible parties may be tried by federal prosecutors for violating the False Claims Act. By following the guidelines above, you can better prevent mistakes from occurring in your documentation.