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Risk Management - Acute Care Hospital: Nursing Documentation

Introduction

The issue of documentation of patient care has received considerable attention in the past few years for a variety of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. Our facility has indicated that nursing documentation is the area of the greatest risk management.

In this era of unprecedented change in healthcare, our facility has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff.

New Approach

The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, but rather as one component of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, the consultants have been working with the risk managers and other professionals to focus on the areas of deficiency or situations that need the most improvement. The cornerstone of the consultative process has been to: 1. pinpoint the exact nature of the medical record deficiency, 2. develop criteria and expectations to improve documentation, 3. describe the current deficiencies as well as expectations for improvement via training and other sources to staff, and 4. develop a method for measuring improvement. The consultative process has taken the following pattern:

Issue identification: The consultant meets with the risk manager to discuss and define the specific area or areas that need to be addressed. This discussion may also include representatives from Nursing, Quality Improvement and Medical Records. Usually, the persons or committees they work with have already identified deficiencies, but have not defined or identified a specific situation or focus. Occasionally, after discussion of some deficiencies, it is concluded that interventions other than training are more appropriate. For example, a systems problem may be identified, such as a particular medical record form that is not well designed and conducive to the documentation of appropriate and complete data. Or, the issue may be more appropriately addressed through supervision and management (e.g. completion of vital signs and intake/output documentation at the end of each shift).

Criteria refinement: The consultant and the risk manager, with other involved staff, work together to specifically define and delineate the areas of deficiency chosen for improvement.

The criteria for proper documentation are determined through reference to accepted nursing standards or principles of risk reduction in medical record documentation.

Baseline data collection: Before the education program, baseline data from medical record audits should be obtained. This data will be compared to data collected after the education program on documentation, to establish its effectiveness. Often the baseline data will already exist. The medical record reviewer or nursing committee who has identified the deficiencies will often have months or more of data already collected, quantifying the extent of the deficiency. If this is the case, it is not usually necessary to perform additional chart audits prior to the intervention.

Intervention: Once the measurement process is in place, the intervention can be initiated. The basis of the intervention is an education program that specifically addresses the identified problem and focuses on the criteria for proper documentation in the specific situation. Other activities can include reinforcement in monthly staff meetings, self-study modules, concurrent review and feedback in the clinical areas and feedback of follow-up audit data to reinforce improvement and/or remind those who are not complying to do so.

Measurement: After the intervention is completed, measurement through data collection takes place. Chart audits should be performed at least quarterly for one year after the intervention, in order to assure the improvement is sustained.

The sample selected for chart audit does not have to be large, but should be sufficient to evaluate various staff members from various departments or units.

Methods Adopted by Other Companies

Nursing Documentation and Workflow Support

Nursing Documentation and Workflow Support provides the automation and communication tools nurses need in today's challenging hospital environment (Rommal, 2002). Efficient, structured workflows make it easier for nurses to document care completely and to comply with increasing regulatory demands. Nurses can streamline common tasks like charting vitals, intake/output, and patient education. Interfaces to patient monitoring devices allow for hands-free, paper-free capture of critical measurements (Health Care Risk Management, 2002).

Activity Assignment Engine automatically populates each care team member's work list with relevant items, helping nurses review and coordinate the care their patients need. The intuitive layout helps nurses organize their day and ensure that all tasks are covered - even across shifts. Template-driven Discharge Instruction Writer ensures complete, relevant patient instructions without a significant administrative burden on nurses (Health Care Risk Management, 2002).

Our Policy

I. Written Entries

All entries made by nursing personnel shall be written in permanent black ink, dated, timed and signed off following each entry by a licensed nurse with full legal signature and classification; or initialed following each entry, signing full name and classification in the space provided at the end of the narrative notes/ MAR once the first initialed entry is made.

II. Incorrect Entry

When an incorrect entry is made in charting, the nurse shall draw a single line through the inaccurate material, making sure it is still legible, write "void” and then initial the voided entry.

Conclusion

Today, nurses not only have to provide high quality patient care, they are required to document everything from past medical history to whether or not the patient wants his or her pastor notified of the admission.  With stringent rules and regulations passed by Medicare and Joint Commission on Accreditation of Health Care Organizations, nurses struggle with the requirements that are put upon them to document complete and accurate patient information.  As nurses enter into the era of computerization, it is important that nurses focus their efforts on improving nursing documentation through the use of computers instead of creating more work for themselves. It is recommended that the nursing documentation is expanded to include greater detail of residents’ care needs and a documented pressure sore risk assessment.

 References

B.C. Health Care Risk Management Society, 2002, Obstetrical Claim Profile, Handle with Care

Rommal C, 2002, Risk Management Issues