INR Features

Question: Are there some general rules concerning documentation? What can happen if a nurse doesn’t chart completely?

Answer: Timely, objective and defensive documentation is but one of several proactive measures undertaken by the nurse to avoid facing a lawsuit or licensing board disciplinary action. This involves knowing how to chart, what to chart, when to chart and who should chart. Without complete documentation, the plan of care, as well as care actually rendered for a patient, may be lost to colleagues, may be legally indefensible, and may result in actual harm to patients.

The Iowa Administrative Code outlines the following standards for licensed nurses in the state: "The licensed nurse shall recognize and understand the legal implications within the scope of nursing practice." (IAC 655- 6.2[1])

"The licensed nurse shall utilize the nursing process in the practice of nursing, consistent with accepted and prevailing practice. The nursing process is ongoing and includes: a] nursing assessments about the health status of an individual or group; b] formulation of a nursing diagnosis based on the analysis of the data from the nursing assessment; c] planning of nursing care which includes determining goals and priorities for actions which are based on the nursing diagnosis; d] nursing interventions implementing the plan of care; and [e] evaluation of the individual’s or group’s status in relation to established goals and the plan of care." (IAC 655- 6.2[2])

Additionally, "if a medical regimen prescribed by a physician is not carried out, based on the licensed nurse’s professional judgment, accountability shall include, but need not be limited to, the following: a] timely notification of the physician who prescribed the medical regimen that the order(s) was not executed and reason(s) for same; and b] documentation on the medical record that the physician was notified and reason(s) for not executing the order(s)." (IAC 655 – 6.2[5]e)

The Iowa Administrative Code further delineates the following authority of the Board of Nursing to discipline licensed nurses for any grounds stated in Iowa Code Chapters 147, 152 and 272C, or rules promulgated thereunder.

In accordance with Iowa Code section 147.55(2), professional incompetency may include, but need not be limited to, the following: "willful or repeated departure from or failure to conform to the minimum standards of acceptable and prevailing practice of nursing in the state of Iowa; willful or repeated failure to practice nursing with reasonable skill and safety; or, willful or repeated failure to practice within the scope of current licensure or level or preparation." (IAC 655 – 4.6[2] c,d,e)

Also in accordance with Iowa Code section 147.55(3), behavior (i.e., acts, knowledge, and practices) which constitutes knowingly making misleading, deceptive, untrue, or fraudulent representations in the practice of a profession may include, but need not be limited to, the following: "falsifying records related to nursing practice or knowingly permitting the use of falsified information in those records." (IAC 655 – 4.6[3]b)

Falsifying the record may not just be limited to the inclusion of false information (i.e. documentation of an assessment which was never performed). Under some circumstances, it is foreseeable that failure to document certain information could be construed as falsification (i.e., patient who is allergic to penicillin was given another patient’s penicillin by mistake, but there is no place in the record which refers to the administration of the penicillin).

Further, in accordance with Iowa Code section 147.55(3), behavior (i.e., acts, knowledge, and practices) which constitutes unethical conduct may include, but need not be limited to, the following: "failing to comply with any rule promulgated by the board related to minimum standards of nursing; or, failing to assess, accurately document, or report the status of a patient or client." (IAC 655–4.6[4]c,k)

There are many different types of charting protocols such as SOAP charting, focus charting, narrative charting, flow-sheet charting, and charting by exception. The appropriateness of the charting format will be based, in part, on the setting in which the practice takes place. Whatever format is used, it is key to always chart clinically significant changes in the patient’s condition. This necessarily requires appropriate documentation of the patient’s baseline, from which the changes may be measured. Documentation should reflect the nursing process as detailed in the assessment of the patient’s condition, the interventions performed by the nurse and the patient’s response.

In addition to state laws and regulations, professional standards for documentation may be gleaned from journal articles written by nurses, as well as by one’s professional association . These standards are the basis by which nursing care will be judged by the Board of Nursing and in the courtroom. Ignorance of the standards is never a sufficient excuse. Although what’s in the charts could hurt you in court, what isn’t in them may hurt you even more. In the absence of nursing documentation, courts could rule that no care was provided.

How well your documentation protects you depends on how well you document. Record the facts of what you see, hear, smell and touch, in an objective manner as possible. Record the information timely. Chart chronologically. Use flow sheets to record routine cares. Be sure to include time/date in your documentation of medical visits/ consultations and discussions about concerns with medical orders and directions.

As a nurse, you are accountable for your actions. The law doesn’t require you to be perfect or to provide the best or the safest care humanly possible – only to meet a reasonable standard. As front-line members of the health care profession, nurses are especially vulnerable to being named in a malpractice lawsuit. You’re not expected to make superhuman efforts to do your job properly – but you are expected to exercise your skills, education, and good judgment to the best of your ability, and meet the standard that a prudent nurse would meet under similar circumstances. If a particular problem is foreseeable, given known facts about a patient, the nurse should take appropriate steps to prevent the particular problem. Keeping the lines of communication with colleagues and patients open will go a long way toward reducing your risk of legal woes.

Nurses are well-advised to remember that it could take years for a legal issue to work its way through the system, and the nurse may have to recall an incident that occurred three to five years ago. As a legal colleague of mine is quick to say, "The faintest ink is better than the clearest memory."

References:

Iowa Administrative Code

Iowa Code

Yocum, Fay (1993), Documentation Skills, Awareness Productions, Tipp City, OH, Pg. xiv.

Philpott, Mary (May 1998), 10 Rules for Good Charting, Springhouse Corp

Wilkinson, Allen P. (June 1998), Nursing Malpractice, Springhouse Corp

Trott, Maureen C. (June 1998), Legal Issues for Nurse Managers, S-N Publications Inc.

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