The world we live in is becoming more litigious with each passing day. Malpractice and neglect are two of the most common reasons that a patient or a family member may file suit against a medical provider. LTPAC nurses need to know how to be proactive and ensure their documentation will hold up in a court of law. Here are my top ten ways to avoid the orange jumpsuit.

Top 10 Tips for Documentation and Compliance

1. Include the following in every entry: Date, time, your title and your signature. This is Nursing 101, but you would be surprised how often it is overlooked.
2. Include all care that has been delegated to other caregivers on your team in your nurses’ notes. This will include tasks delegated to a RN, LPN or LVN, and/ or Certified, or State Tested Nursing Assistant (CNA/ STNA). If you have assigned a task to another caregiver also ensure that it is documented that the task was completed – or if not, why. Do not delegate and leave it, follow up and make sure that the outcome is documented.
3. Include any patient refusals for medication, therapy, care and/or treatment and your number of and types of attempts to re-approach the patient. Documentation must be clear in order to avoid a negative outcome due to the resident refusal. We must satisfy the resident/patient right to refuse treatment but we must try to engage with them as to WHY they are refusing. Perhaps they are refusing treatment due to excessive pain? Perhaps the medication makes them sick to their stomach? These are situations we can help rectify if we listen. In any case, we must document both the refusal and what we as caregivers did to try to turn the situation around.
4. Include all patient changes in condition in your assessments and narrative notes, including notification of physician, physician assistant or other practitioner as well as the patient family. Including these changes and the notification in your documentation will help to ensure that all caregivers are on the “same page” and watching for additional changes or improvement with treatment.
5. Include in your nurses’ notes any patient or family training completed prior to discharge. You will have your documentation to back you up if there is ever a question regarding the education you provided.
6. Always write legibly and check your spelling. It goes without saying that if you are called to read your own documentation during a deposition or a trial, you are going to have an issue if the note is not legible and/or clear.
7. Always ensure you are documenting in the correct chart. (Yes, it happens!) Charting in the wrong medical record is just plain sloppy, and one could ask the question “what else is this nurse doing carelessly?” That is an easy assumption for a surveyor or litigator to make.
8. Always read back verbal orders to help ensure accuracy. Even if the order came through loud and clear over the phone, always repeat the order back to the practitioner.
9. Always write and sign your own orders and assessments. If you do not, this may give the perception that you are willing to cut corners.
10. Always document about your patient in an objective and unbiased way. Your note should never include negative statement or bias. Objectivity is the only the way to go.

For more help with your documentation and compliance practices, contact the experts at Richter Healthcare Consultants at 866.806.0799 to learn what we can do for you.