DOCUMENTATION IN OBSTETRICAL CRISIS

1. DOCUMENTATION IN OBSTETRICAL CRISIS Cyndy Krening, MS, RNC-OB, C-EFM Perinatal Clinical Specialist

2. OBJECTIVES • List 5 DO’s and DON’Ts of documentation • Identify common situations that expose nurses to documentation risk and liability • Discuss documentation strategies to minimize liability

3. “If caring were enough, anyone could be a nurse”

4. WHY IS DOCUMENTATION SUCH A BIG DEAL? • It’s your legacy • Most likely you will not remember • It’s the most important evidence in a lawsuit

5. “Professional care is elevated by professional charting”

6. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Failure to adhere to guidelines • Evaluation for PTL • FHR pattern interpretation • Failure to communicate with provider • Neonatal resuscitation • Oxytocin

7. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Oxytocin

8. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Oxytocin

9. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Oxytocin

10. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Failure to follow orders • Lack of informed consent • Chain of command • Failure to document • Timely cesarean birth • Shoulder dystocia • Instrumented vaginal birth • Second stage management

11. WHAT GETS NURSES INTO DOCUMENTATION TROUBLE? • Second stage management

12. MEDICALRECORD FUNCTIONS • Communication • Chronological record • Insurance billing • Quality assurance • Legal document • Potent defense against lawsuits “The medical record is the care rendered, if it isn’t in the record, it didn’t happen”

13. “The medical record is the patients’ other self”

14. GOOD DOCUMENTATION • Records pertinent observations • Coordinates patient care • Improves your professional credibility • Acts as a future reminder “The palest ink is better than the strongest memory”

15. TRUE OR FALSE? It is important to document the filing of an incident (occurrence) report so that there’s a record of it.

16. Have the patient’s name on every sheet Make sure you have the correct EMR open Make entries in chronological order Use black ink Sign each entry Write neatly, legibly Use concise phrases Use accepted abbreviations Be objective, describe Document action following indication Document chain of command DO’S OF DOCUMENTATION

17. DO WRITE LEGIBLY!

18. TRUE OR FALSE? Time of delivery should be taken from a atomic clock that everyone can see.

19. Draw through mistaken entries with single line, date, initial Remember writing skills Use ‘out of sequence’ for entries during the same shift Document patient behavior Use quotes Precisely document information reported to the provider Transcribe orders carefully Synchronize all timepieces DO’S OF DOCUMENTATION

20. Rely on memory to chart the entire shift Tamper with notes previously written Erase, white out Chart in advance Imply disaster Understate Chart for anyone else Skip lines Discard anything Leave a space before your signature Add extraneous remarks, joust Exaggerate DON’TS OF DOCUMENTATION

21. DON’TS OF DOCUMENTATION Version #1

22. DON’TS OF DOCUMENTATION Version #2

23. TRUE OR FALSE? It is important to keep a journal of sentinel events that occur so that you’ll have detailed notes in case you need them in the future.

24. Advertise incident reports Assign blame Try to keep secrets Sound tentative Make private notes about a sentinel event Refer to staffing problems Chart on the EFM tracing unless it’s an emergency Leave unexplained time gaps Block chart Interject personal opinions Characterize patient negatively DON’TS OF DOCUMENTATION

25. ILL CHOSEN WORDS CAN COME BACK TO HAUNT YOU “Frequent flier” “Patient in extreme pain because previous nurse too busy to give pain meds”

26. RISK FACTORS Urgency of decision making process High risk climate Staff stress High technology Technical competence Multiple documents

27. PITFALLS • No monitor tracing • No interpretation of assessment • Medical vs nursing diagnosis • Untimely documentation • Medication dosages • No indication of nursing intervention

28. PITFALLS • Medication dosages

29. PITFALLS • No indication of nursing intervention

30. PITFALLS • No indication of nursing intervention

31. PITFALLS • No follow-up evaluation of interventions • Chart wars • Uninterpretable monitor tracing • Unclear charting “The chart can be your best friend or worst enemy”

32. PITFALLS • Uninterpretable monitor tracing

33. PITFALLS • Unclear charting

34. PITFALLS • Unclear charting

35. PITFALLS • Unclear charting

36. PITFALLS • Unclear charting

37. POLICIES & PROCEDURES Methods of assessment Frequency of assessments Qualifications of providers performing assessments Nurse/patient ratios Acceptable abbreviations Methods of documentation

38. RULES OF THE GAME • Baseline; rate, stability of rate, variability • Decelerations; name, recovery • Non-periodic changes • UC and their relationship to the FHR • Nursing Diagnosis • Plan of care “What you don’t chart can hurt you”

39. “The results and benefits of nursing documentation are greater than the sum of the tasks themselves”

40. STRATEGIES TO MINIMIZE RISK Know the standards Professional Facility Community Continuing education Workshops Journals National organization membership Certification

41. STRATEGIES TO MINIMIZE RISK Patient advocacy SBAR Chain of command Thorough documentation

42. CHARTING DEFENSIVELY How to chart What to chart When to chart Who should chart

43. CHARTING DEFENSIVELY How to chart Stick to the facts Avoid labeling Be specific Use neutral language Eliminate bias Keep the record intact

44. CHARTING DEFENSIVELY What to chart Significant situations Complete assessment data Discharge instructions

45. CHARTING DEFENSIVELY When to chart When you perform nursing care or shortly afterward

46. CHARTING DEFENSIVELY Who should chart Never ask another nurse to complete your charting Never complete another nurse’s charting

47. QUESTIONS? “A good chart defends itself and those who made it”

48. REFERENCES BNET (2000). Charting defensively. Nursing, 1-3. Brous E (2010). Documentation and litigation: Best practices for nurses. RN Web. Downloaded 2/16/10. Garza M (2004). Avoid these common charting errors in labor and delivery. OB-GYN Malp Prev, Mar, 17-21. Hudson K (2009). Legal documentation. DynamicNursingEducation.com, 1-5. Lowes R (2008). Chart mistakes that can burn you. Contemp OB/GYN, Mar, 47-52. McCarthey PR (2009). Audit trails and electronic record discovery. MCN, 34 (1). 64. McConnell EA (1999). Do’s & don’ts; Charting with care. Nur 99, 29 (10), 68. Navuluri RB (2000). Charting tips; The six honest servants of good documentation. Nur, 39 (6), 22. Sullivan GH (2000). Legally speaking; Keep you charting on course. RN, 63 (5), 75-9.