Defensive Documentation from an Expert Witness Perspective

Transcription

1 Defensive Documentation from an Expert Witness Perspective Arizona Health Care Association Strive For 5 ALL THINGS LEGAL April 14, 2016 Linda L. Palmer, RN, LNHA Long Term Care Training/Consulting 1

2 Defensive documentation is thoroughly documenting resident care or the circumstances surrounding a resident incident/issue. It is documentation penned with the awareness that the entry may be reviewed at a later date to find fault or identify a breach in the standard of care provided to a resident. 2

3 NURSES UNANIMOUSLY BELIEVE THAT CARING FOR THE RESIDENT IS THE MOST IMPORTANT THING In our litigious society, documentation protects patients well-being, nurses livelihood, and facility survival In our world (our nursing home world), documentation truly does become secondary to patient-care priorities 3

4 The tricky thing about defensive documentation is that our staff doesn t always know what charting is going to be under the microscope in the future. It s easy to recognize a significant change in a resident and carefully document assessment and follow-up. But frequently in routine matters, documentation can be sketchy or missing. 4

5 Why have a medical record? Clearly documents a resident s condition Clearly records what care and services were delivered Provides a way for the resident s medical providers to keep current on changes in the resident s condition Provides a way for the resident s medical providers to communicate with each other 5

6 Why have a medical record (con t) Records who played a role in a resident s care Provides a way to determine the quality of care delivered Provides documentation for reimbursement purposes **The key is clearly communicating a resident s condition** 6

7 Charting by exception (CBE) vs. If it wasn t charted, it wasn t done CBE trainers indicate that if interventions, expected outcomes, and patient responses weren t charted using symbols to reflect predefined norms, and variances weren t defined in detail-then it wasn t done. Charting by exception is not a short cut-it is a tool. Leaving out critical documentation makes it that much harder for a defense attorney or expert to help a defendant. Correct use of Charting by Exception helps in the defense of a facility. 7

8 TIPS TO HELP YOUR NURSE EXPERT WHEN IN LITIGATION Document personal follow-up on complaints/concerns and attempts at resolution Chart to the Care Plan Know your residents and their families be able to call them by name and use that information in your documentation 8

9 Document Care Plan conference summaries that include family/resident participation and involvement DON T DOCUMENT JUST TO MEET THE REGS Monthly Summaries? ADL Flow Sheets? Meal Percentages? Activity Participation Records? 9

10 Make positive notes and cards from families or residents part of the resident s record Policies & Procedures lots of em?? Policies---quantity vs. quality 10

11 Electronic Health Records You must ensure, through ongoing inservice and during orientation that standard charting protocol especially in narrative notes is adhered to by all staff documenting in a chart Staff should NEVER sign in under another staff members login to document resident cares. This is a breach in medical records standards 11

12 JURIES RELY HEAVILY ON NURSES CHARTING Lack of documentation implies lack of care to jurors Nursing documentation must make sense, must have meaning, and must communicate clearly If it is not in the chart, there is a good chance the jury will never see it 12

13 In a Nutshell: Detailed nursing notes are your best defense in validating the care you provide Complete accurate ADL sheets-especially turning, fluids, and meal intake Document clearly and completely on Incident/Event Reports Document all communications with the medical provider 13