Documentation 101: What Every Nurse Needs To Know To Help Avoid Liability Risks

by: Georgia Reiner
Senior Risk Specialist for Nurses Service Organization (NSO) in the Healthcare Division of Aon’s Affinity Insurance Services, Inc.

Documentation is a tool for the planning and provision of patient care, communication among providers, and demonstration of compliance with federal, state, third-party payer and other regulations. Documentation provides a picture of the patient’s condition and how they respond to treatment, which influences the decisions that subsequent providers will make regarding the patient’s care. It is also a legal record that reflects the quality of care you provided. Inadequate documentation may not only impede the quality of patient care, it can also hinder the nurse’s legal defense in the event of a malpractice lawsuit and can even lead to a nursing board license complaint.

Below are some do’s and don’ts to keep in mind while charting.

Documentation Do’s
• Make sure that the correct chart is being used
• All documentation should reflect the nursing process and the full extent of a nurse’s professional capabilities
• Complete descriptions are always needed
• Record the time medication was administered, the administration route, and the patient response
• Precautions or preventative measures used, like bed rails, must be accounted for
• All phone calls to physicians, including the exact time, message, and response need to be charted
• In the case a patient refuses to allow a treatment or take medication, document it and be sure to report to a manager and the patient’s physician
• Patient care should be documented at the time you provide it— details can be easily forgotten over time.
• When adding something to a chart, make sure to document the information with a notation that it is a late entry and include the time and date
• Always document often enough and with enough detail to tell the entire story

Documentation Don’ts
• Don’t chart symptoms without also charting how it was treated
• Never alter a patients’ records— that is a criminal offense
• Don’t include shorthand or abbreviations that aren’t widely accepted
• Don’t use imprecise descriptions, such as “bed soaked” or “a large amount”
• Never chart excuses, such as “Medication not administered because it wasn’t available”
• Don’t chart what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks
• Don’t chart care ahead of time— situations often change and charting care that has not been performed is considered fraud
Ultimately, the importance of maintaining documentation skills cannot be overemphasized. The key to a strong legal defense for nurses facing malpractice claims is quality documentation. This is evidenced by the Nurse Professional Liability Exposures: 2015 Claim Report Update from CNA and Nurses Service Organization (NSO), which analyzed 549 closed nurse professional liability claims (claims that resulted in a payment for a settlement or judgment of $10,000 or greater) over a 5-year period.

The report’s analysis showed that most professional liability claims against nurses stemmed from an alleged failure involving core competencies, including patient assessment and monitoring. Missing or incomplete documentation hindered legal defense in many of these cases. CNA and NSO’s closed claims analyses also found that 9.1 percent of nurse Board of Nursing paid claims were due to allegations of documentation errors or omissions, with an average defense expense of $4,124 per claim.

Maintaining a consistent, professional patient health information record is essential to providing quality patient care, ensuring consistent communication among all professionals caring for the patient, and establishing the basis for an effective defense should litigation arise. By following best practices, nurses can minimize their risk of making a documentation error and potentially facing a lawsuit as a result.