Upon completion of this module, the learner will be able to:
- Describe the importance of nursing documentation and list the essential components of documentation with regards to professional nursing standards.
- Describe how nursing documentation has shifted with the transition toward electronic medical records (EMRs).
- Identify the legalities of nursing documentation.
- Recognize common documentation errors, contributing factors, and ‘do not use' medical abbreviations according to The Joint Commission.
The purpose of this module is to provide an overview of nursing documentation, outlining the professional standards, most common documentation errors and legal risks of nursing documentation in the face of evolving technology and reliance on electronic medical records.
Thorough and accurate documentation is considered a professional standard of nursing practice, serving to safeguard patient care, reduce the potential for miscommunication and errors, and promote quality outcomes (Woods, 2019). The American Nurses Association (ANA, 2010a) views the registered nurse as individually responsible and accountable for maintaining professional competence. Documentation is a valuable method for demonstrating that the nurse has applied appropriate nursing knowledge, skills, and clinical judgment according to professional nursing standards. Documentation must not only meet professional and employer standards, but it must also meet criteria required by the legal system (Woods, 2019).
Overview of Nursing Documentation
The quality and coordination of patient care depend upon the extent and usefulness of communication among all members of the patient's healthcare team, with the medical record serving as the central vehicle of this interaction (Woods, 2019). In the modern era of healthcare, communication is primarily through recording and reporting (Krishna, 2017). Therefore, high-quality documentation is a necessary, indispensable, and predominant component across all facets of nursing care. Nursing documentation is defined as the process of preparing a complete record of handwritten or electronic evidence regarding a patient's care. It includes nursing assessment, nursing care plan (highlighting the patient's healthcare needs and outcomes), along with interventions, education, and discharge planning. Accurate, timely, and detailed documentation shows the extent and quality of the nursing care provided, the outcomes of that care, as well as any treatment and education that the patient still requires (Woods, 2019). Proper documentation establishes professional accountability and demonstrates nursing knowledge and judgment skills. It also verifies that the patient received care according to the institution's policy, industry standards, and state regulations (ANA, 2010a).
Beyond fostering quality and continuity of care, comprehensive and precise nursing documentation serves several other purposes. It is vital for quality assurance, as accrediting agencies and other regulatory bodies use documentation to evaluate the quality of care a patient receives. Insurance companies and payors use documentation systems to verify the care received and render payment to the organization. It is a legal document that becomes a central part of proving if standards of care were met or not when legal issues arise. It may also be used for research and education and can help organizations assess funding and resource management (Woods, 2019).
The ANA's Principles for Nursing Documentation (ANA, 2010a) expects that high-quality nursing documentation follows regulatory guidelines and mandates across all nursing roles and working settings. Last revised in 2010, this document remains the gold standard for the basis of nursing documentation, with six essential principles serving as primary guidelines, as outlined in Table 1 (ANA, 2010a). Nurses must also acquire a keen awareness and understanding of their state's nurse practice act to ensure documentation reflects specific state laws. Further, nursing documentation includes the organization's choice of forms and technology, requiring the nurse to additionally adhere to policies and procedures established by the facility (ANA, 2015).
Table 1. ANA’s Six Essential Nursing Documentation Principles
Defines high-quality nursing documentation as inclusive of the following characteristics: "Accessible, accurate, relevant, consistent, auditable, clear, concise, complete, legible/readable, thoughtful, timely, contemporaneous, sequential, reflective of the nursing process, and retrievable on a permanent basis in a nursing-specific manner" (ANA, 2010a, p.12).
Education and Training
Nurses must receive adequate training and education on the various facets of nursing documentation according to professional standards, in addition to the employing organization's policies and procedures. Training must include competency in the use of the electronic medical record (EMR) system specific to the employing institution, as well as proficiency in any site-specific software utilized. Nurses must be provided with adequate time to complete documentation.
Policies and Procedures
The nurse must become familiar with organizational policies and procedures pertaining to documentation, as well as maintaining efficiency during EMR downtime, or periods of electronic system malfunction.
The medical record (paper-based or electronic) must offer appropriate security measures protecting data and patient information according to the organization, industry standards, and government mandates. This includes regulations set forth by the Health Insurance Portability and Accountability Act (HIPAA), which mandate patient confidentiality practices.
Everything entered into the medical record must be "accurate, valid, and complete; authenticated (factual), the author is identified, and nothing has been added or inserted; dated and time-stamped by the person who created the entry; legible/readable; and composed using standardized terminology including acronyms and symbols" (ANA, 2010a, p.14).
Nurses should document utilizing standardized terminology to describe the planning, delivery, and evaluation of nursing care. Using standardized terminology helps with data aggregation and analysis
Nurses must also be familiar with the ANA's Scope and Standards of Practice (2015) which outlines the required competencies of nursing documentation utilizing critical thinking and the nursing process. The standards state that nurses must document the following:
- Relevant data accurately and in a manner accessible to the interprofessional team;
- Diagnoses, problems, and issues in a way that facilitates the determination of the expected outcomes and plan;
- Expected outcomes as measurable goals;
- The plan using standardized language or recognized terminology;
- The implementation and any modifications, including changes or omissions, of the identified plan;
- The coordination of care;
- The results of the evaluation; and
- Contribute to quality nursing practice by documenting nursing practice in a manner that supports quality and performance improvement initiatives (ANA, 2015).
Paper-Based Records vs. EMR
The evolution of healthcare information technology over the last several decades has steered the field of healthcare from paper-based medical records to nearly complete reliance on EMRs and technology for all aspects of patient care. Some institutions continue to utilize certain aspects of paper charting, and the EMR serves as a complement to the paper record. However, the vast majority have transitioned to wide-ranging, all-encompassing EMR-based systems (O'Brien, Weaver, Settergren, Hook, & Ivory, 2015). The EMR and paper medical records typically contain the same documents, as the EMR is primarily viewed as a digital version of a patient's paper chart, but they are profoundly different. EMRs have reshaped healthcare delivery. They offer many tools and features designed to enhance communication among healthcare providers, increase productivity, and improve the quality and utility of clinical documentation (Evans, 2016).
The EMR allows information to be stored in one place that is easily accessible by all members of the healthcare team. This facilitates timely intervention when acute changes occur in the patient's clinical status. The EMR simplifies communication exchange, allows providers to order medications, tests, or procedures when external to the unit, as a means of expediting quality care and improving outcomes. The EMR also meets many of the criteria of Principle 1 of the ANA’s Six Essential Nursing Documentation Principles. The EMR enhances accessibility to the patient’s chart for all members of the team and simultaneously from various locations. The EMR facilitates the ability to audit the medical record, allowing for easier evaluation, and tracking of data. It eradicates the concern for legibility by removing the variable of handwriting, however documentation must still be 'readable' and requires proper grammar. The EMR facilitates the timely, contemporaneous, and sequential aspects of charting, as the majority of EMRs automatically timestamp entries, allowing for immediate, fast and precise timeline of documentation entries. Further, information is retrievable on a permanent basis, as the computer system saves information immediately, removing the possibility of lost paper records and charts (ANA, 2010a).The EMR is also useful in the management of patients with complex health conditions and comorbidities, enhancing follow up and continuity of care. Many EMRs offer time-saving features, such as automated processes that improve clinical accuracy, accompanied by tools to improve patient safety and decrease the overall cost of healthcare (Evans, 2016).
Whether nursing documentation is paper-based or electronic, the requirements remain the same; clear and concise patient care information, reflecting responsible professional judgment, signed, time-stamped, and dated within an appropriate time frame (ANA, 2015). While there are many additional benefits associated with the EMR that extend beyond those highlighted within this module, there are also several pitfalls and dangers regarding documentation that did not exist with traditional paper-based documentation. For example, while "auto-populate," "cut-and-paste," and "copy forward" features have been designed as time-reducing efficacies, they have also enhanced the margin for documentation error and carelessness by copying forward inaccurate information inadvertently (Evans, 2016). Further, documentation in the EMR can be even more limited than in paper-based records. Completion of pre-populated assessment templates and checkboxes generally do not provide an accurate depiction of the patient's clinical status. If all checkboxes are not entirely filled out, it may appear that blank items were not addressed or not observed by the nurse. Nurses have been surveyed regarding their perceptions of documentation processes during the period of transition from paper to electronic systems and the majority describe concerns regarding redundancy, excessive time away from direct patient care, inadequate training in the functionality and use of the EMR system, and increased amount of overtime required to complete documentation (Krishna, 2017; O'Brien et al., 2015).
Unfortunately, the current state of various EMR systems have been shown to increase the burden of documentation for many nurses, further distracting from the ability to deliver personalized, evidence-based practice (EBP), and efficient patient care. While EBP is a core competency among the nursing profession, the majority of EMR systems are not yet equipped to guide the delivery of EBP (Evans, 2016). The majority of nursing documentation within the electronic record is consistent with data entry, as many systems offer discrete fields in flow sheet rows and columns instead of free text. This type of nursing documentation omits valuable aspects of patient care, creating several gaps and inconsistencies in the patient's overall clinical picture. Furthermore, regulatory and accreditation requirements associated with the EMR also increase the documentation burden imposed on nurses and tend to contribute to data redundancy (O'Brien et al., 2015). Nonetheless, despite the challenges the EMR system poses, nurses are obligated to perform safe and high-quality patient care with supporting documentation (Capriotti, 2020).
Legalities of Nursing Documentation
The medical record is often the most critical piece of evidence in a malpractice lawsuit (McWay, 2016). Nursing documentation is evidence that the patient received proper care. In a court of law, the patient's health record serves as the legal record of the care provided to that patient to defend against allegations of malpractice, negligence, or failure to meet standards of care (Jacoby & Scruth, 2017). Legally, the term standard of care is defined as:
Ethical or legal duty of a professional to exercise the level of care, diligence, and skill prescribed in the code of practice of his or her profession, or as other professionals in the same discipline would in the same or similar circumstances. Failure to meet the standard of care is considered negligence, and the healthcare provider will be held liable for any damages caused by such negligence. (Edwards, 2017, p.1)
Professional negligence is a failure to provide the standard of care to a patient, resulting in an injury or damage to the patient. In the event of a lawsuit, an omission is a form of neglect, which is where the renowned phrase "if it wasn't documented it wasn't done" comes into play (Jacoby & Scruth, 2017).
A case commonly referenced in malpractice literature is the case of Susan Meek V. Southern Baptist Hospital of Florida in 2006. In this case, the patient was admitted to the hospital for a hysterectomy, which is the surgical removal of the uterus. Postoperatively, she developed abnormal bleeding and required a uterine artery embolization to stop the bleeding. Due to the known risk of diminished blood flow and subsequent nerve injury to the lower extremities, the physician ordered frequent leg exams. The patient suffered nerve damage after a blood clot was removed from the external iliac artery, and the patient claimed the leg exams were not performed. Due to the lack of nursing documentation, it remains unknown if the nurses performed the leg examinations or not. Therefore, based on the absence of documentation, the patient won the lawsuit and was awarded $1.5 million in damages (Edwards, 2017).
One of the cardinal principles of legally defensible documentation is adherence to organizational policy and procedures, standards of care, guidelines, competencies, and any other organizational documents that guide the care of patients. Improper documentation can leave an employer (and the nurse) liable and vulnerable to a malpractice lawsuit. In the event of a deviation from any of these policies, the nurse must clearly support the basis for the variation within his or her nursing documentation (McWay, 2016).
Among all types of nursing errors, lack of attentiveness and documentation errors are among the most frequently cited categories across the literature (Eltaybani, Mohamed, & Abdelwareth, 2018).
Factors Contributing to Documentation Errors
Root cause analyses have revealed that nursing documentation errors are commonly due to lack of awareness, high workload demands, redundant information, and lack of standards. Omission or errors in nursing documentation can also be due to a lack of training of nurses. Mistakes can be enhanced by the design of certain charting forms, which can be complicated, time-consuming, difficult to navigate, and not user-friendly (ANA, 2015). Other causes include a lack of standards on nursing documentation, poorly defined institutional policies, and inadequate knowledge, awareness, and training. Staffing shortages and heavy workloads can result in insufficient time to chart, as nurses devote most of their time to direct patient care responsibilities (Krishna, 2017). Nurses' perceptions and resistance to documenting also contribute to documentation errors, as nurses view documenting as an obligation rather than a professional responsibility. Further, nurses describe heavy workloads as factors generating perceptions that documenting is less critical. As a result, the quality of the documentation is compromised, and errors are inevitable (Lindo et al., 2016).
Some of the most common types of nursing documentation errors include:
- Illegible handwriting (less of a factor with EMRs);
- Incomplete or missing documentation such as failure to record nursing activities;
- Failure to date, time, and sign a medical entry (many EMRs do this automatically now);
- Lack of documentation justifying omitted medications or treatments;
- Documenting subjective data;
- Not questioning incomprehensible orders from medical providers;
- Using the wrong abbreviations or those that are not approved;
- Entering information into the wrong patient’s chart;
- Not recording patient care activities or drug-related information, including a drug reaction or any change;
- Documenting prior to care given; and
- Delayed entries (Edwards, 2017; Eltaybani et. al., 2018; Krishna, 2017)
Documenting Medical Errors
In 1999, the Institute of Medicine (IOM) released the report To Err is Human: Building a Safer Health System, revealing that preventable adverse events in hospitals were a leading cause of death in the United States. The report cited that approximately 44,000 to 98,000 people die annually as a result of medical errors (Havens & Boroughs, 2000). This gave birth to the notion that reporting errors is fundamental to preventing errors, which gave rise to mandatory reporting systems. These systems were created to foster healthcare environments in which safety is the top priority. Currently, there remains a wide range of mandatory reporting requirements for healthcare facilities at the federal, state, private sector, and accrediting organization levels. Among states, there is a wide variation in the types of individual events reported. According to the National Academy for State Health Policy (NASHP, 2015), there are 27 adverse event-reporting systems across 26 states and the District of Columbia.
According to Standard 9: Communication of the ANA's Scope and Standards of Practice, professional competency and expectation of the registered nurse is that h/she discloses concerns related to potential or actual hazards and errors in patient care or within the practice environment to the appropriate level. This includes any errors made by the nurse (ANA, 2015, p. 71). Each organization offers its own policy on the manner in which medical errors are reported and documented. Generally, medical error reporting occurs through a standardized form or online reporting system and is governed by a partnership between the state agency representatives and the healthcare organization's policy. However, the Joint Commission (JCAHO) requires accredited healthcare agencies to report sentinel events, which is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (Mascioli & Carrico, 2016). By recognizing medical errors, learning from them, and working toward preventing them, patient safety can be improved (Rodziewicz & Hipskind, 2019).
Reducing Professional Risk Through Documentation
To reduce the risk of medical errors, JCAHO created the "Do Not Use" list of abbreviations (see Figure 1 below). The list applies to all orders and medication-related documentation, whether handwritten, computer entry, or on preprinted forms (JCAHO, 2019).
Most documentation errors are preventable if proper precautions are taken. Table 2 provides a compilation of documentation "do's and don'ts," as accumulated through a detailed review of existing literature. These documentation tips are designed to guide nurses in ensuring every entry in the medical record reflects high-quality and safe patient care (Capriotti, 2020).
Table 2. Nursing Documentation Do’s & Don’ts
For All Types of Medical Records (Paper and Electronic):
Special Considerations for Paper-Based Records:
Special Considerations for EMR Systems:
(ANA, 2010a; Capriotti, 2020; Lavin et al., 2015; Starr, 2016; Woods, 2019)
Critical Thinking: Reflective Case Study
Mr. Jones is a 42-year-old patient with a past medical history of hypertension, diabetes mellitus, chronic pain, alcoholism, and clinical depression. Mr. Jones is admitted to the medical-surgical nursing unit related to complications of his uncontrolled diabetes. He has an open wound on his left lower extremity and is on intravenous antibiotics for a diagnosis of cellulitis. He requires daily wound debridement to irrigate the wound. Tara is the registered nurse assigned to the day shift care of Mr. Jones, as well as five other patients on the unit. During morning shift change, she received report that Mr. Jones was "non-compliant" with his medications throughout the night, refusing to take any medicines and ordering the nursing staff to leave his room. When Tara attempted to bring Mr. Jones his morning medications including his antihyperglycemics and antibiotics, Mr. Jones became acutely agitated and ordered Tara to leave his room. Tara tried to reason with Mr. Jones, explaining the risks of refusing his diabetes medications and his antibiotics. She warned him of the risk of worsening infection and severe illness. Mr. Jones shook his head and ordered her to leave. At that point, Tara decided to allow Mr. Jones some time to rest and opted to pass medications and care for her other patients, with plans to return to Mr. Jones later. Tara returned to Mr. Jones's room about two hours later, and he again yelled for her to leave his room immediately. Frustrated, Tara called Mr. Jones's treating physician to alert him of the difficulties with administering medications and risk for harm to his health conditions. In the interim, another patient on Tara's schedule became acutely ill, and Tara's attention was diverted from Mr. Jones for the next few hours. Tara finally connected with Mr. Jones' physician later in the day who seemed unphased by the information provided to him. Concerned, Tara reached out to her nurse manager for assistance, who also visited the patient and attempted to reason with him.
Nearing the end of her shift, Tara realized she had not charted on Mr. Jones throughout the day. She logged onto the EMR and completed the institution's required checklist-based nursing assessment flowsheet, intentionally leaving blank the physical examination section since the patient refused to allow her to examine him. In the end, she entered a short progress note that stated the following, "The patient is grumpy and angry, yelling at nursing staff. He was noncompliant with care. No acute events or falls." Two days later, Mr. Jones became acutely ill with sepsis, as the cellulitis infection of his lower extremity progressed to a bloodstream infection. Mr. Jones was transferred to the intensive care unit (ICU) and died from cardiopulmonary arrest 24 hours later.
Identify the red flags surrounding Tara's nursing documentation and describe ways in which Tara rendered herself and her employer liable for a malpractice lawsuit. Provide examples of how her documentation could be improved.
There are several red flags in this case surrounding documentation errors and omissions. Some of these include:
- Tara did not chart in ‘real-time' with each encounter; she waited until the end of the day.
- She used subjective opinions and judgments in her notation instead of listing factual data.
- She did not document her inability to perform the physical assessment on the checklist. She instead left the areas blank, which implies that this was not addressed or overlooked and could be considered negligence.
- Tara did not list the essential interventions she performed to remedy the problem (i.e., notifying the physician, alerting the nurse manager, and educating the patient).
Below are some examples of high-quality documentation that would reduce Tara's and the institution's liability:
- Medical Entry #1: "Attempted to assess Mr. Jones at 7:50 AM after receiving the morning report. Mr. Jones did not allow for the physical assessment and refused his morning dose of Metformin and Penicillin." Tara Smith, RN, 9/29/19, 8:00 AM
- Medical Entry #2: "Re-attempted to assess Mr. Jones at 9:35 AM. Mr. Jones again expressed frustration with being disturbed and refused medication administration with Metformin and Penicillin. I paged Dr. Harold at 9:45 AM." Tara Smith, RN, 9/29/19 9:52 AM
- Medical Entry #3: Documentation of the nursing assessment flowsheet:
- N/A selected for each physical assessment component
- Free text notation added: "Unable to perform physical assessment due to patient refusal. Dr. Harold paged at 11:45 am." Tara, Smith, RN, 9/29/19 11:55 AM
- Medical Entry #4: "Nursing manager notified of the inability to provide nursing care to the patient. This situation was discussed with Dr. Harold at 2:00 PM by telephone. The nurse manager spoke with the patient. The patient was counseled on the risks of refusing medical care and his medications, including worsening infection and other health complications." Tara, Smith, RN, 9/29/19 2:10 PM
This case cites many of the potential issues identified within this module as problematic with nursing documentation. The evidence portrays Tara as being overwhelmed and burdened by her heavy nursing assignment and tending to her sick patients, which left her with little time to document. While Tara attempted to educate Mr. Jones on the risk of worsening illness and complications associated with refusing his medications on more than one occasion, yet she did not document this communication exchange in the record. She also neglected to document that she paged the physician twice, and finally connected with the physician later by telephone. She also did not document that she spoke with her nurse manager regarding the issue, who also spoke directly with the patient. Therefore, all of these actions appear to have never happened in the eyes of the law and/or any other medical reviewer. Tara's documentation is lacking, supports her role in professional negligence, and contributing to poor patient outcomes. It does not accurately depict the events of the day, the actions of the nurse, or the remainder of the healthcare team.
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