Documentation Guidelines for the Clinical Record hcpro
Documentation Guidelines for the Clinical Record is published by HCPro, Inc. Copyright 2006 HCPro, Inc. All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN 1-57839-759-6 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark. Mike Michaud, Graphic Artist Mike Mirabello, Cover Designer Jean St. Pierre, Director of Operations Paul Amos, Group Publisher Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. P.O. Box 1168 Marblehead, MA 01945 Telephone: 800/650-6787 or 781/639-1872 Fax: 781/639-2982 E-mail: customerservice@hcpro.com Visit HCPro at its World Wide Web sites: www.hcpro.com and www.hcmarketplace.com 1/2006 20645-A
Contents The clinical record............................1 The purpose of documentation..................3 Who may write in the clinical record...................3 Date and time of entries in the chart..............4 Use of time blocks................................4 Example 1: Timing and dating entries..................5 Advance entries, predating, and back-dating.............5 Signatures.................................6 Signature components..............................6 Countersignatures.................................6 Initials....................................7 When to use initials................................7 Legibility...................................8 Example 2: Illegible nurses notes.....................8 Use ink.........................................9 iii
CONTENTS Chronology of entries........................10 Document in chronological order.....................10 Example 3: Documenting in chronological order..........11 All fields/blocks are to be filled......................12 Basic documentation rules.....................13 Factual and objective information.....................13 Quality of entry content............................15 Speculation.....................................16 Contradictory entries..............................16 Omissions, additions, clarifications, and corrections in documentation..................17 Late entries.....................................17 Example 4: Late entries............................18 Addenda.......................................19 Writing a clarification..............................20 Omissions on medication/treatment records, graphic, and other flow sheets.............................21 Documenting care provided by another nurse...........23 Error correction..................................24 Example 5: Misspelled words........................25 Example 6: Information documented in wrong chart......25 Bibliography...............................26 iv
Documentation Guidelines for the Clinical Record The clinical record The patient s clinical record, commonly referred to as the chart, is used by all members of the healthcare team to record, preserve and communicate the patient s progress and current treatment. It provides a record of the patient s health status, including observations, measurements, history, and prognosis, and serves as the primary document describing the healthcare services provided to the patient. The chart also is used to determine the appropriateness and quality of care by describing the services provided to the patient providing evidence that the care was necessary documenting the patient s response to the care and changes made to the plan of care 1
The chart also provides supporting documentation for the reimbursement of services provided to the patient is a source of data for clinical, health services, and outcomes research, as well as public health purposes serves as a major resource for healthcare practitioner education, is the legal business record for a healthcare organization, and provides support for business decision-making is maintained as required by law 2
The purpose of documentation Documenting events, occurrences, interactions, and outcomes in a clinical record serves many purposes, including regulatory, clinical, financial, and administrative. The predominant purpose of the clinical record is to maintain continuity of care from caregiver to caregiver. Nurses and others who write in the chart must select words and phrases not only to satisfy the goal of effective communication, but also to assist third-person auditors obtain necessary information. Staff members making written entries in a clinical record should ask the following questions: What is the purpose of the entry? Does the language selected communicate clearly to other team members? Does the note satisfy its intended purpose? Who may write in the clinical record Centers must look to state law for guidance on who may write in the clinical record. Entries in the clinical record should be made by members of the patient s healthcare team and those with a center or patient-approved purpose only, as mandated by HIPAA. The center must safeguard the clinical record and limit access to those individuals who are entitled to the protected health information contained within it. 3
Date and time of entries in the chart Begin each clinical record entry with the month, day, year, and time of the entry. Include the time in narrative notes, even though it may not seem important for the type of entry being made. If it is necessary to summarize events that occurred over a period of time (e.g., a shift), the notation should indicate the actual time the entry was made with the narrative documentation identifying the time at which the relevant events occurred. Use of time blocks It is rarely acceptable to chart time as a block, especially for narrative notes. Narrative documentation should reflect the actual time the entry was made (see Example 1: Timing and dating entries ). For certain types of flow sheets (e.g., the treatment administration record), recording time as a block may be acceptable. For example, a treatment that can be delivered any time during a shift could have a block of time identified on the treatment record with staff confirming with a signature that they delivered the treatment during that shift. 4
EXAMPLE 1 TIMING AND DATING ENTRIES DATE TIME CLINICIAN ENTRY 01/12/05 1:00pm Patient coughing non-productively. Lung sounds are clear. Temp 99. Denies chest pains or shortness of breath. No edema noted to extremities. Denies runny nose or headache. 01/21/05 1:10pm 01/22/05 1:20pm 01/22/05 1:40pm 01/22/05 1:50pm Patient does not want to get up out of bed. Too tired. Denies any discomforts. Dry cough. PRN Robitussin given with some relief. Resting dressed on bed. Patient not up and about. Only complains of feeling tired. This is very unusual for patient. B/P 100/50 P 100 R22 T102 Lungs with crackles. Call placed to Dr. Jones. Chest x-ray ordered. Mobile x-ray on the way. X-ray completed. Placed call to patient s spouse to make him aware of change. Tylenol pm given. Resting in bed with head elevated. Mobile called and patient has pneumonia. Dr. Jones made aware and patient being readied for transport to Acute Care Hospital. Name Last First Middle Attending Physician: Record Number: When multiple individuals complete the form, indicate the date and time of completion as well as who completed each section of the form. Complete entries concurrently with the performance of a service or the observation of an event, but in all instances, chart as soon as possible after an event has occurred or an observation is made. Advance entries, predating, and back-dating Do not make entries in advance. Predating or back-dating an entry is both unethical and potentially illegal. Complete entries using the actual date and time the entry is made. 5
Signatures Entries in the clinical record are to be signed by the person making the entry. This includes all types of entries (e.g., narrative notes, progress notes, assessments, flow sheets, orders, etc.), whether in paper or electronic format. Signature components All entries in the clinical record are to be authenticated by the author. At a minimum the signature should include the first initial, last name, and title or credential. If there are two people with the same first initials and last names, both must use their full signatures and middle initials, if applicable, to avoid confusion. Countersignatures The need for countersignatures for healthcare providers (e.g., physician assistants, nurse practitioners, student or graduate nurses and therapy assistants) is controlled by state law. The person who makes the countersignature must be qualified to countersign as permitted by state laws, regulations, and center policy. 6
Initials Whenever a center chooses to use initials in any part of the record for authentication of an entry, there must be corresponding full identification of the initials on the same form or a signature legend. Each person who documents with initials in the clinical record must have a corresponding full signature on record. Two methods that may be used include the following: A signature legend can be included on the actual form where the initials are used The center may keep one master signature legend. The master signature legend must include an implementation date and the initials, full signature, and title of staff. A copy of the master signature legend must be easily accessible and maintained and updated by the center. A new master signature legend must be completed once a year to maintain a current list of authors. When to use initials Initials can be used to authenticate entries (e.g., flow sheets, medication records, or treatment records) but should not be used in such entries as narrative notes or assessments. Do not use initials where a signature is required by law (e.g., on the Minimum Data Set). 7
Legibility Entries in the clinical record must be legible. Readable documentation assists other caregivers and helps to ensure continuation of the patient s plan of care. Conversely, if entries cannot be read, information critical to the care of the patient may not be communicated. Even the most informative notes are useless if other caregivers cannot read them. A poorly written record is of no help when a staff member is called to remember what occurred two or three years later and the only reminder is an illegible note (see Example 2: Illegible nurses notes ). EXAMPLE 2 ILLEGIBLE NURSES NOTES Date/Time Prob.# Notes must be signed with name and title Name Last First Middle Attending Physician: Record Number: 8
If a recently completed entry cannot be read, the author should legibly rewrite the entry on the next available line, referring back to the original documentation. For example, start with Re-written entry of [the original date of the entry being rewritten], then rewrite the entry, date it when re-written, and sign it. The rewritten entry must be the same as the original. Use ink Entries in the clinical record, regardless of form or format, should be made in ink so that the record is permanent and changes are noticeable. Dark blue ink is preferred because it makes it easier to distinguish originals from photocopies, but black ink is also acceptable. The ink should be permanent (no erasable or water-soluble ink should be used). Never use a pencil to document in the clinical record. 9
Chronology of entries Document in chronological order The record should tell a story of the patient, his or her needs, the care and services provided, and the outcome. The clinical record can assist in the defense of the patient s care in the event of an inquiry by state surveyors or a lawsuit. It can show not only that things were done, but also that they were done to best meet the needs of the patient. Keeping the record in order can help everyone follow the story. If an entry is made out of chronological order, it should be documented as a late entry (see Example 3: Documenting in chronological order ). 10
EXAMPLE 3 DOCUMENTING IN CHRONOLOGICAL ORDER DATE TIME CLINICIAN ENTRY 01/14/05 4:00pm Nurse assistant reported that patient on the floor in room. Upon entering the room, patient was lying on her right side at the bathroom doorway. She was alert and oriented x3. Careful assessment of all extremities did not reveal pain, discomfort, internal or external rotation. Patient could move extremities through ROM. Patient denies hitting head and no bruises, lumps or lacerations noted. Patient denies dizziness or nausea before or after the fall. Patient assisted up per two to her bedside without any problem. BP 128/76 P76 R 18 T 98.4. Patient then assisted to her chair and was able to walk without difficulty. When questioned about how the fall occurred, she said she just did not know, it happened so fast. 01/14/05 4:15pm 01/14/05 6:30pm Call placed to Dr. Primary to report fall. No new orders at this time. Contacted daughter Joann to report 4:00pm fall. Patient remains alert and oriented x3. No bruising noted to right side of body. Call light within reach and patient reminded not to get up without assistance. Has been independently ambulating since admitted without an assistive device. Wears sneaakers. Was not on the way to the BR. There have been no recent changes to medication or recent illness. CNA walked next to patient to and from meals. Gait steady as usual. Patient states, I am fine, just getting clumsy I guess. In room watching game show at present. Call light within reach and patient reminded to let nursing staff know if she needs anything. BP 124/70 P 72 R18 T 98.6 Name Last First Middle Attending Physician: Record Number: 11
All fields/blocks are to be filled On some standardized assessments, flow sheets, and checklist documents, some of the questions or fields may not be applicable to the patient. To avoid the inference that care was not provided, all fields or blocks should have an entry. If a field is not applicable, an entry such as N/A or another abbreviation accepted by the center should be made to show that the question was reviewed and answered. 12
Basic documentation rules Factual and objective information Do not let emotions influence or appear in charting. The clinical record should contain only objective, factual information that pertains to the direct care of the patient. These guidelines should be followed no matter what event is being documented, but can be particularly important when documenting incidents that may or may not have caused a patient injury (e.g., falls). Entries in the clinical record should include only the facts objective data without opinion or assumptions physical evaluation details details of conversations or interactions with the patient actions taken to care for the patient details of conversations with the physician and the noting of his or her orders or directives implementation of the physician s orders or directives details of conversations and responses with the family 13
The clinical record should be a compilation of factual and objective information about the patient. The record should not be used to voice complaints about other caregivers, departments, physicians, or the center, fights between disciplines, gripes, staffing issues, vendor issues, etc. The clinical record is not an appropriate place to voice personal feelings about a patient or a patient s family. 14
Quality of entry content The clinical record is not solely a timed and dated history of the patient s care. The effectiveness of the clinical record as a patient care communication and continuity tool also depends largely upon the quality of each entry. This means each entry should have meaningful content that enables subsequent care givers to understand what care has been provided and the reasons for the care decisions made, and to evaluate the significance of later patient outcomes. The quality of the chart s content, however, is reflected not only in the information conveyed in the given entries, but perhaps more importantly, by the information mistakenly or intentionally omitted. The type of information that is most commonly omitted is, unfortunately, also the type of information that may be most important to the overall record. Some examples are: patient and family education conversations with the patient and family members, in person or per telephone cues/redirection given to a patient encouragement of food and fluid intake conversations with physicians or other practitioners, in person or per telephone one-on-one time or visits with patients family requests and responses to those requests 15
Speculation Do not speculate when documenting. The record should reflect only factual information (i.e., what is known, not what is thought or presumed) and should be written using factual statements. Personal opinions that are unrelated to a medical diagnosis should not be used when charting. Document what can be seen, heard, touched, and smelled. Describe objective signs and symptoms, and the patient s response to care. Document verbatim the patient s version of events or complaints, and use quotation marks to quote the patient. Document all facts and pertinent information related to any deviation from ordered treatment, including the reason for it. Make sure the entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum, or clarification. Contradictory entries If an entry is made that contradicts previous documentation, the new entry should explain why there is a contraindication. Charting should be free of statements that blame, accuse, or compromise other caregivers, the patient, or his or her family. 16
Omissions, additions, clarifications, and corrections in documentation There will be times when it will be necessary to make an entry that is late or out of sequence or provide additional documentation to supplement entries previously written. Late entries A late entry is used to record information in the clinical record when a pertinent entry was missed or not written in a timely manner (i.e., during the shift of work). There is not a time limit to writing a late entry; however, the more time that passes, the less reliable the entry may become. Document late entrries as soon as possible. When making a late entry: Identify the new entry as a late entry Enter the current date and time do not try to give the appearance that the entry was made on a previous date or at an earlier time Identify or refer to the date and incident for which the late entry is written 17
If the late entry is used to supply omitted information, validate the source of the information as much as possible where you obtained the information to write the late entry (e.g., by using supporting documentation on other facility worksheets or forms) (see Example 4: Late entries ). EXAMPLE 4 LATE ENTRIES Driving home after a busy day, the nursing assistant remembers that a shower was given to Mr. Jones that was not documented. When the nursing assistant returns to the center the following day, the missing data is entered in the appropriate space on the ADL Worksheet and a circle is drawn around it. On the reverse side of the ADL Worksheet, the nursing assistant documents, Late entry for date of [date shower was actually given] and provides the current date and signature. 18
Addenda An addendum is a type of late entry that is used to provide additional information in conjunction with a previous entry. An addendum is appropriate where a previous note has been made, and the addendum provides additional information to address a specific situation or incident. Addendums are used to supply additional information only, not to correct earlier notes. Complete an addendum as soon as possible after the original note. When making an addendum: Document the current date and time Write addendum and state the reason for the addendum, referring back to the original entry Identify any sources of information used to support the addendum 19
Writing a clarification A clarification is a type of late entry. It is written to avoid incorrect interpretation of previously documented information. Use a clarification when there is a concern that an entry could be misinterpreted. Complete a clarification as soon as possible after the original entry. When making a clarification: Document the current date and time Write clarification, state the reason and refer back to the entry being clarified Identify any sources of information used to support the clarification 20
Omissions on medication/treatment records, graphic, and other flow sheets Going back to earlier days charting and filling in signature holes on medication and treatment records or other graphic or flow records is considered willful falsification and is illegal. Follow the center s established procedures for making a late entry when there is total recall and other supporting information to prove that a medication or treatment was administered. Some States have established time frames in which omissions can be completed if the staff member recalls administering the medication or treatment. It is recommended that all staff members complete medication, treatment, graphic or flow records within their shifts of work and only when having a clear recollection of administering the medication or treatment or other information pertinent to a graphic or flow record. 21
When an omission is identified, for example, after completion of the staff member s shift after a patient has been transferred from the center when the staff member does not have a clear recollection of whether the treatment or medication was given, or when there is no supporting documentation (e.g., worksheets, narcotic records, drug delivery records, initiated punch cards, etc.) the omission is circled and initialed with the omitted information documented as a late entry note either on the back of the Medication Administration Record (MAR), Treatment Administration Record (TAR), or in nurses notes or interdisciplinary notes. If medications, treatments or other physician-ordered interventions were not administered, the following steps should include: Notification of the physician Implementation of any new orders Documentation of patient response Notification of family Notification of other authorities as required by law 22
At the end of each shift, each staff member should audit his or her own charting for completeness, making additional entries in conformity with the procedures described in this handbook or within established guidelines. At no time should a center conduct largescale chart audits where the intent of the audit is to fill-in holes. Documenting care provided by another nurse Each nurse should document his or her own observations, data, etc., in the clinical record. In rare circumstances, a nurse may document conversations reflecting care that was provided by others. For example, if a call is received from a nurse from the previous shift who indicates that he or she forgot to chart something in the patients clinical record, the nurse accepting the call may document the date and time of the telephone call, the name of the individual making the call and the content of the conversation. 23
Error correction The inappropriate correction of errors in documentation has serious legal implications. There will be times when documentation mistakes occur and changes will be necessary (see Example 5: Misspelled words and Example 6: Information documented in wrong chart ). Corrections of charting errors should be made as soon as possible after the original entry. If an error is made in a clinical record, draw a single line through the entry using a thin pen line. Make sure that the inaccurate information is still legible. initial and date the entry. state the reason for the error in the margin or above the note if there is room. record the correct information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line or space, documenting the current date and time and referring back to the incorrect entry. do not obliterate or otherwise alter the original entry by blacking it out with a marker, using White-out, or writing over the entry. 24
EXAMPLE 5 MISSPELLED WORDS 10/1/05 Patient went to show room. A. Aide, CNA. Correction: shower A. Aide, CNA, 10/1/05 10/1/05 Patient went to show room. A. Aide, CNA. EXAMPLE 6 INFORMATION DOCUMENTED IN WRONG CHART Information for Mrs. Jones was accidentally charted in Mr. Miller s chart. 10/1/05 Mrs. Jones ambulated 20 ft. without assistance A. Aide, CNA. Correction: Mistaken entry A. Aide, CNA, 10/1/05 10/1/05 Mrs. Jones ambulated 20 feet without assistance A. Aide, CNA. 25
Bibliography Tra Beicher, Defensive Documentation for Long-Term Care: Strategies for creating a more lawsuit-proof resident record (Marblehead, MA: HCPro, Inc., 2003). Long-Term Care Pocket Guide to Nursing Documentation (Marblehead, MA: HCPro, Inc., 2004). 26
I have received and reviewed a copy of the HCPro Documentation Guidelines for the Clinical Record. I understand the information contained in this Handbook and agree to comply with the instructions provided within. Employee s Signature: Date: Supervisor s Signature: Date: Location: