Part I: Documentation and Reporting

Key Objectives of Documentation and Reporting

• Use standard professional guidelines for effective nursing documentation.

• Identify measures to protect confidential patient information.

• Identify approved abbreviations and symbols, and distinguish them from error-prone ones.

• Describe the purposes of different types of patient health records.

• Compare and contrast different methods of documentation.

• Describe the purpose and correct use of various formats for nursing documentation.

• Recognize that documentation must be complete, accurate, current, and concise because the patient health record is a legal document.

• Describe the nurse’s role in communicating with other health care professionals through reporting.

💡 Definition and Purpose of Documentation

Documentation is the written or electronic legal record of all pertinent interactions with the patient.

• It includes data related to: assessing, diagnosing, planning, implementing, and evaluating.

• Key Phrase: "If it's not documented, it wasn't done," which emphasizes the legal and clinical importance of recording all actions thoroughly.

Purposes of Documentation:

• Facilitates quality, evidence-based patient care.

• Serves as a financial and legal record.

• Essential for billing and legal accountability (lack of documentation may jeopardize legal cases).

• Helps in clinical research.

• Supports decision analysis.

✍ Characteristics of Effective Documentation

Documentation should be:

• Consistent with professional and agency standards.

• Complete.

• Accurate.

• Concise.

• Factual.

• Organized and timely.

• Legally prudent.

• Confidential.

Format and Structure Considerations:

• Use the 24-hour cycle Military Clock for documenting times to avoid confusion.

• Documentation must reflect the nursing process and be objective and measurable (avoid ambiguous terms like "good" or "normal").

• Record any precautions and preventive measures taken.

🔒 Confidentiality and Patient Rights (HIPAA)

Confidential information includes all information about patients, whether written on paper, spoken aloud, or saved on a computer.

What is Confidential:

• Name, address, phone, fax, social security number.

• Reason the person is sick.

• Treatments the patient receives.

• Information about past health conditions.

Potential Breaches in Patient Confidentiality:

• Displaying information on a public screen.

• Sending confidential e-mail messages via public networks.

• Sharing printers among units with differing functions.

• Discarding copies of patient information in trash cans.

• Holding conversations that can be overheard.

• Faxing confidential information to unauthorized persons.

• Sending confidential messages overheard on pagers.

Patient Rights (HIPAA-Ensured): Patients have the right to:

• See and copy their health record.

• Update/request correction of their health record.

• Get a list of disclosures (independent of disclosures for treatment, payment, and health care operations).

• Request a restriction on certain uses or disclosures.

• Choose how to receive health information.

🗣 Handling Verbal Orders

Verbal orders (VO) are risky and should be limited to urgent situations.

Policy Requirements:

1. Must be given directly by the physician or nurse practitioner (NP) to a registered professional nurse (RN) or registered professional pharmacist (RPh).

2. Record the orders in the patient’s medical record with the initials VO.

3. Read back the order to verify accuracy.

4. Date and note the time orders were issued.

5. Record the verbal order and name of the physician or NP issuing the order, followed by the nurse’s name and initials.

6. The physician or NP must review the orders for accuracy, sign them (with name, title, and pager number), and date/note the time signed.

🗂 Methods and Systems of Documentation

📋 Formats for Nursing Documentation

• Initial nursing assessment.

• Nursing care plan; patient care summary.

• Critical/collaborative pathways.

• Progress notes.

• Flow sheets and graphic records.

• Medication administration record.

• Acuity record.

• Discharge and transfer summary (brief overview of treatment and significant findings).

• Home health care documentation.

• Long-Term care documentation.

🏥 Specialized Documentation

• Long-Term Care Assessments (RAI): Utilizes a resident assessment tool for continuous monitoring and individualized care planning.

  • Minimum Data Set: A set of screening, clinical, and functional status elements that form the comprehensive assessment.

  • Triggers: Responses for one or more of the data set elements.

  • Resident assessment protocols: Identify social, medical, nursing, and psychological problems for care planning.

  • Utilization guidelines: Direct when and how to use the RAI.

  • Benefits: Residents respond to individualized care, staff communication improves, family involvement increases, and documentation becomes clearer.

• Home Health Care: Documentation must establish the need for Medicare reimbursement.

  • Medicare Requirements: Patient is homebound, still needs skilled nursing care, rehabilitation potential is good (or patient is dying), status is not stabilized, and the patient is making progress in expected outcomes.

  • OASIS (Outcomes and Assessment Information Sets) is a tool for tracking quality in home health care.

📞 Reporting and Handoff Communication

Reporting is how nurses communicate with other health care professionals.

• Change of Shift/Handoff Report:

  • Includes basic identifying information (name, room, diagnosis, physicians).

  • Current appraisal of health status.

  • Current orders (especially newly changed ones).

  • Abnormal occurrences during the shift.

  • Any unfilled orders that need continuation.

  • Patient/family questions, concerns, needs.

  • Reports on transfers/discharges.

• ISBARR/SBAR: A methodology widely utilized for reporting patient information and ensuring clear communication.

  • Identity/Introduction.

  • Situation.

  • Background.

  • Assessment.

  • Recommendation.

  • Read back of orders/response.

• Telephone/Telemedicine Report:

  • Identify yourself, the patient, and your relationship.

  • Report concisely and accurately the change in condition and what actions have already been taken.

  • Report current vital signs and clinical manifestations.

  • Have the patient’s record available.

  • Concise record time, date, communication details, and physician’s response.

⚖ Part II: Legal Dimensions of Nursing Practice

🏛 Legal Concepts and Sources of Law

• Law: A standard or rule of conduct established and enforced by government, designed to protect the rights of the public.

• Types of Law:

  • Public Law: Government is directly involved; regulates relationships between individuals and the government.

  • Private Law (Civil Law): Regulates relationships among people; facilitates civil actions such as lawsuits.

  • Criminal Law: Concerns state and federal criminal statutes; defines criminal actions (e.g., murder, theft).

• Sources of Law:

  • Constitutions: Serve as guides to legislative bodies.

  • Statutory Law: Enacted by a legislative body (e.g., the Nurse Practice Act).

  • Administrative Law: Empowered by executive officers; regulations put forth by agencies (e.g., boards of health).

  • Common Law: Created by the judiciary system through reconciling controversies.

👩‍⚕ Professional and Legal Regulation of Nursing Practice

• Nurse Practice Acts: Define the legal scope and standards of nursing practice and address violations that may result in disciplinary actions.

• Standards: Guidelines established by professional organizations.

• Credentialing: Process ensuring competence through verification of credentials.

  • Accreditation: Program evaluation ensuring standards are met.

  • Licensure: State-regulated process certifying qualifications, clinical competence, and moral character.

  • Certification: Recognizes specialization in a field.

Reasons for Suspending or Revoking a License:

• Drug or alcohol abuse.

• Fraud or deceptive practice.

• Criminal acts.

• Previous disciplinary actions.

• Gross or ordinary negligence.

• Physical or mental impairments.

🚨 Criminal Law vs. Torts (Civil Law)

Intentional Torts

• Assault: Threatening action that causes fear of harm.

• Battery: Actual offensive physical contact without consent.

• Defamation of Character: False statements harming a person's reputation.

• Invasion of Privacy: Unauthorized disclosure of private patient information.

• False Imprisonment.

• Fraud.

Unintentional Torts

• Negligence: Failure to act in a manner consistent with the established professional standard of care, potentially resulting in patient harm.

• Malpractice: Specific type of negligence with more stringent requirements, usually involving a professional standard.

🛡 Malpractice and Liability

Four Elements of Liability (Proof of Malpractice):

1. Duty: Obligation of care that a nurse must provide.

2. Breach of Duty: Failure to meet that standard.

3. Causation: Proving that the breach directly caused the injury.

4. Damages: The harm or injury suffered by the patient as a result.

Common Categories of Malpractice Claims:

• Failure to follow standards of care.

• Failure to use equipment in a responsible manner.

• Failure to assess and monitor.

• Failure to communicate.

• Failure to document.

• Failure to act as a patient advocate.

• Failure to follow the chain of command.

🧑‍⚖ Roles of Nurses in Legal Proceedings

• Nurse as Defendant: The person being accused.

  • Recommendations: Do not alter patient records; cooperate fully with your attorney; be courteous on the witness stand; and do not volunteer any information.

• Nurse as Fact Witness: Testifies about exactly what they observed.

• Nurse as Expert Witness: Explains to the court what the standard of nursing care is and whether that standard was met.

📝 Incident, Variance, or Occurrence Reports

Incident reports document occurrences out of the ordinary, primarily for quality improvement rather than punitive measures.

Information Contained in Incident Reports:

• Complete name of person(s) and names of witnesses.

• Factual account of the incident.

• Date, time, and place of incident.

• Pertinent characteristics of person involved.

• Any equipment or resources being used.

• Any other important variables.

• Documentation by the physician of the medical examination of the person involved.

🔑 Legal Safeguards for Nurses

• Competent practice.

  • Safeguards include respecting legal boundaries, following institutional policies, owning personal strengths/weaknesses, evaluating proposed assignments, keeping current in nursing knowledge, respecting patient rights, and keeping careful documentation.

• Informed Consent or Refusal: Essential process involving understanding and agreement for treatment.

• Executing provider orders.

• Delegating nursing care.

• Appropriate use of social media.

• Professional liability insurance.

• Good Samaritan Laws: Provides legal protection to those who assist others in emergency situations and limits liability when care is rendered outside of a professional setting.

• Risk management programs.

• Patients’ rights.