Defensible Documentation for Nurses

Defensible documentation for nurses

How well would your documentation hold up in the face of litigation? Defensible documentation for nurses may help protect from the threat of malpractice.

The recent guilty plea of a Pennsylvania nurse for misdemeanor neglect and tampering with records has once more brought the topic of defensible documentation for nurses into the spotlight.

According to a report by the Philadelphia-based law firm Raynes & Lawn, an average of 20,000 medical malpractice lawsuits are filed each year in the United States. In many cases, documentation accuracy could mean the difference between a revoked license and an ongoing career.

A defense against malpractice

At its core, documentation should provide a nurse with an indisputable defense against malpractice. This defense is built carefully, meticulously, with detailed paper trails beginning from the moment the nurse first sees a patient.

In the best case scenario, this defense proves unnecessary. If the worst should happen, however, and a clinical error results in patient harm or death, the nurse who provided care has a clear outline of what happened and why.

Related: Criminally Negligent Homicide and Patient Safety

What is defensible documentation?

As Julie Lenhardt, a health policy expert based in Catonsville, MD, describes it, “defensible” documentation clearly outlines the medical necessity of the care being provided. Included in this is the rationale as to why the skills of a specific clinician was required at each stage in the treatment.

This clinical reasoning should be expressed through clearly defined goals and a prognosis for the plan of care, as well as outcomes and response to treatment. “Indefensible documentation is not client-centered, is generic, does not outline why an intervention was necessary, and lacks details and clinical reasoning,” Lenhardt says.

Related: Legal Issues for Nursing Documentation, 4th Edition

Practical tactics

The Nurses Service Organization (NSO), the largest provider of nursing liability insurance in the U.S., suggests a few simple tactics to ensure defensible documentation.

Some of the NSO’s do’s include:

  • Before entering information, check that the correct chart is being used
  • Ensure that all documentation reflects the nursing process and the full extent of the nurse’s professional capabilities
  • Use complete descriptions for note-taking
  • Chart the time that patient care procedures are delivered and the time that medication is administered, as well as the administration route and the patient’s response to treatment
  • Chart all precautions taken and/or preventative measures taken
  • Record any phone calls with physicians, including the time, message, and response of the communication
  • Document when patients refuse to allow for a treatment to be provided or a medication to be administered. Report to a manager and the patient’s physician.
  • Make notations to documentation when information is added, and not that there is a late entry with the time and date included

Things to avoid

The NSO also suggests the following don’ts when it comes to documentation:

  • Don’t alter a patient’s record
  • Don’t use shorthand notes or abbreviations that aren’t widely accepted
  • Avoid imprecise descriptions, such as “bed soaked” or “a large amount”
  • Unless the information is critical, do not chart someone else’s thoughts. If this type of note-taking is needed, use quotations and properly attribute the remarks.
  • Don’t chart care ahead of time or care that has not been performed

Why do documentation errors happen?

While the use of EHRs should result in fewer mistakes due to programmed safeguards, Lenhardt warns that there always remains a certain margin of error.

“The whole point of moving towards EHRs was to make medical records accessible to all care providers and to eliminate siloed care, so that an individual patient can be treated holistically with streamlined care, and thus eliminating the potential for costly mistakes and duplicative care,” Lenhardt says. “But if the EHRs can’t ‘talk’ to each other efficiently, the system is failing the patient. A lack of interoperability between EHRs and healthcare information exchanges (HIEs) can cause confusion.”

Also complicating the process is the fact that clinicians must often document for multiple stakeholders. “You need to demonstrate that your services are skilled and medically necessary for the payer, that clinical outcomes are significant for the referring provider, and that you are client-centered and meaningful for the client [or patient],” says Lenhardt. “It can be overwhelming to meet all of those needs in one record. In addition, productivity and efficiency demands are immensely challenging, resulting in healthcare practitioners feeling pressure to do more things faster, which is a perfect setup for documentation errors.”

High pressure, high stakes

Lenhardt says that the administrative burden tends to be the biggest reason she’s seen for documentation errors over the years. “Clinicians contend with multiple, sometimes competing, requirements, depending on the payer source and other interested parties, and it can quickly become overwhelming, inevitably leading to errors,” she says. “Additionally, reimbursement for services has slowly declined for most clinicians. So, for a smaller practice, there is a certain amount of pressure to see more patients to counterbalance the loss of income.”

In her experience, Lenhardt says that providers are not afforded enough time to appropriately document. “Appropriate documentation requires clinicians to be thoughtful and purposeful in their documentation to establish medical necessity, goals, outcomes, prognosis, and informed consent,” she said. “As more is required of clinicians to justify care, it pushes the clinician to squeeze more out of their time.  When you add in specific payer requirements such as prior authorization, which may need separate forms to be completed, it can certainly add up to become the primary activity during the course of the day.”

Additional challenges

The ongoing COVID-19 pandemic has both exacerbated time management challenges and resulted in improved documentation competence, Lenhardt says.

“Documenting for services provided via telehealth was a huge learning curve for clinicians early on in the pandemic,” she says. “But it also forced clinicians to be creative in their approach to care and allowed them to be thoughtful about treatment and careful about documentation, especially as use of telehealth services increased. I think many clinicians realized that telehealth services would be scrutinized more closely, especially as the pandemic entered its second year. Hence, it forced them to take a closer look at their documentation.”

A thoughtful approach

As long as humans are involved in the documentation process, there will be the risk of human error. Even so, clinicians can take mitigating steps to lessen these risks.

Officials with the American Nurses Association (ANA) suggest that nurses in all settings and at all levels should be active participants in the documentation decision-making.

From the employer standpoint, the ANA encourages nurses to collaborate with administration and risk management staff on the creation, design, selection, and implementation of documentation systems. This creates opportunities for all stakeholders to impact the quality of documentation systems, policies, and processes.

The ANA also calls on nursing programs to improve their students’ documentation skills. Curricula should include didactic and clinical components. Equipping nurses with the skills they need to practice defensible documentation from the very start of their careers protects not only nurses, but also the patients they serve.

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