1
DOCUMENTATIONAs a Loss Prevention Technique
For Advanced Practice Nurses
2
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.
3
Legal Perspective on Documentation
Not documented, not done.
Poorly documented, poorly done.
Incorrectly documented, fraudulent.
4
Quality Documentation Reflects Quality Care
Structured documentation typically inspires structured performance.
Document the Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
5
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
6
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
You Are Judged By How You Document (continued)
7
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
8
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
9
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
10
Basis for Reimbursement
Your documentation will influence how you and your employer are reimbursed for services rendered and may minimize financial loss.
11
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.
12
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
13
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
14
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
15
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
16
Considerations for Quality Documentation
Do Enter: Contemporaneous documentation
Accurate documentation
Do Not Enter: Fraudulent documentation
Inappropriate documentation
17
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.
18
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.
19
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”
20
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
21
10 Documentation Strategies1. Do not erase, use “white out”, or cross out an error
with more than one line2. Record only the patient’s statements, clinical facts,
observed behavior, and health services rendered3. Do not criticize other health care providers or
document your personal opinions4. 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)
22
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
10 Documentation Strategies
23
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.
10 Documentation Strategies
24
Communication Challenges
Attributes: Factual
Accurate
Current
Confidential
25
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
26
Documentation Techniques
27
Documentation TechniquesSOAP
S: Subjective
O: Objective
A: Assessment
P: Plan of Care
28
SOAP
Strengths Address specific problems
Organized
Problem List
Notes show continuity of care and evaluation and resolution of problems
Eliminates nonessential data
Weaknesses Can be inflexible
Routine care can be difficult to document
Time-consuming
Difficult to decide where to place data
29
SOAP (SOOOAAP) Expanded method that includes additional
risk-reduction techniques
Opinion, Options, Advice, Agreed Plan
Documentation Techniques
30
Narrative Chronological account of events in a
free-form, sentence-based structure
May include columns or sections to organize information
Documentation Techniques
31
Narrative
Strengths Simplified method
Control
Chronological
Adaptable
Easy to teach or learn
Weaknesses Lack of guidance
Freeform can produce notes that are:
– Fragmented
– Rambling
– Inconsistent between authors
– Non-informative
32
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
Documentation Techniques
33
Electronic DocumentationStrengths Legible
Prompting
Changes tracked
Modifiable system
Consistent
Easy to find
Entries are time and date stamped
Weaknesses Facility must make major
cash investment
Training
Possibility of software or hardware crash
Major psychological change
Inaccuracies
34
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
Documentation Techniques
35
Open ChartingStrengths 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
36
HIPAA and Documentation
Security Rule and Privacy Rule
The Security Rule Documentation standard has three implementation specifications.
– Time Limit (Required)
– Availability (Required)
– Updates (Required)
37
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
38
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
39
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.
40
Learn Your Organization’s Guidelines
– Treatment-related injuries– Missed/incorrect diagnosis– Employee exposures– Facility-acquired pressure sores
– Patient falls– Medication errors– Equipment failure– Complaint by patient, family,
visitor
Examples of Reportable Incidents
41
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
42
Quality Monitoring
Participate in investigations and analysis of the cause of the incident
Maintain confidentiality of all information
43
Case StudyFailure 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 anit-coagulant 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
44
Case StudyFailure 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
45
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
Case StudyFailure to Assess Resident - 78 year old female
46
Case StudyFailure 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
47
Case StudyFailure 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
48
Case StudyFailure 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.
49
Case StudyFailure 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
50
Case StudyFailure 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
51
Case StudyFailure 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
52
Documentation Examples
53
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
54
Sample Medical RecordDate: May 7, 2010Patient Name: Tom JonesChief 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 HypertensionHypertension 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, photorxDiabetic Autonomic Neuropathy Type I (250.61)No Exercising RegularlyHypertension (401.9)Red Blood In Bowel Movement (Hematochezia) Resolved (578.1)Reported Prior Thyroid Disease.eg
55
PSH Bone Grafting With Microvascular Anastomosis Iliac CrestColonoscopy (Fiberoptic); 2005-tics, ih, polp-3 yrsHysterectomy (V45.77)No SurgerySurgery Of Male Genitalia Vasectomy (V25.2)Tonsillectomy.eg
Current Meds Prilosec 10 MG Capsule Delayed Release;TAKE 1 CAPSULE DAILY; RPTKlonopin 2 MG Tablet;TAKE 1 TABLET TWICE DAILY AS NEEDED.; RPTCombiPatch 0.05-0.14 MG/DAY Patch Biweekly;; RPTStaticin SOLN;APPLY AS DIRECTED.; RPTStatins Support MISC;TAKE KIT; RPTStatins Depletion MISC;TAKE KIT; RPT.eg
Allergies Aleve TABSPenicillin G Pot in Dextrose SOLNSulfa Drugs.eg
56
Family Hx No Family history of Coronary Artery DiseaseFamily history of Diabetes MellitusNo Family history of Essential HypertensionFamily history of Family Health StatusFamily history of Family Health Status Brother 1; 0Family history of Family Health Status Brother 1; x2x1-deceased car accidentx2
healthyFamily history of Family Health Status Father; deceased colon cancerFamily history of Family Health Status Number Of Children; 2 boys twinsNo Family history of Family Health Status Of Mother - AliveFamily history of Family Health Status Sister 1; x3Family history of Family Health Status Sister 1Family history of Hyperlipidemia; FatherFamily history of HypertensionFamily history of Reported Family History Ischemic Heart Disease Before Age 50No Family history of Malignant Carcinoma Of The Breast; motherNo Family history of Malignant Neoplasm Of The Large IntestineNo Family history of Reported A Family History Of AlcoholismNo Family history of Reported A Family History Of Congenital Heart DiseaseFamily history of Reported Family History Ischemic Heart Disease Before Age 50No Family history of Thyroid Disorder
57
Personal Hx Alcohol; OccasionallyNo Behavioral HistoryBeing A Social DrinkerCaffeine UseCigars (___ A Day) (V15.82)Currently In SchoolDaily Coffee Consumption (___ Cups/Day); 3 cups dailyDaily Cola Consumption (___ Cans/Day); 1 dailyNo Daily Tea Consumption (___ Cups/Day)Drinking In Moderation (2 Drinks / Day Or Fewer)No Drug UseExercise HabitsNo Exercising RegularlyMarital History - Currently Married
Never SmokedOccupation:; Self employedNo Secondhand Tobacco Smoke In HomeNo Smoking CigarettesNo Smoking Cigarettes For ____ Pack-yearssocial history reviewed; lives w/ mom, dad, 2 yr old brother joe, 1 dog , no
smokersNo Tobacco Use
58
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
59
Inadequate Documentation1. 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
60
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)
61
Documentation Bloopers “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 69-year old male, mentally alert but forgetful.”
“Patient has two teenage children, but no other abnormalities.”
“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.”
62
DisclaimerThe purpose of this presentation is to provide information, rather than advice or opinion. It is accurate to the best of the company’s knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional. In addition, CNA does not endorse any coverages, systems, processes or protocols addressed herein unless they are produced or created by CNA. Any references to non-CNA Web sites are provided solely for convenience, and CNA disclaims any responsibility with respect to such Web sites.
To the extent this presentation contains any examples, please note that they are for illustrative purposes only and any similarity to actual individuals, entities, places or situations is unintentional and purely coincidental. In addition, any examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice. Use of the term "partnership" and/or "partner" should not be construed to represent a legally binding partnership. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2010 CNA. All rights reserved.