Document carefully to prove your actions
By Elizabeth E. Hogue, Esq.
Burtonsville, MD
There is an old saying among health care providers: "If you did not document it, you did not do it." Harsh as this adage may sound, generally it still is true. Staff members frequently do the right thing in the course of patient care, but fail to document the quality of care that was rendered to patients. Then, when care is questioned, practitioners are in a much more vulnerable position than they would have been in if the treatment was properly documented.
Providers must be especially meticulous with regard to documentation of:
- monitoring and observation of patients;
- physician responses to reports of changes in signs and symptoms;
- receipt of laboratory results within appropriate time periods;
- patient falls;
- additions or corrections to documentation in patients’ charts.
Staff members are responsible for monitoring patients for changes in signs and symptoms and to report them to patients’ attending physicians. They have the responsibility to perform an adequate initial patient evaluation and also are required to continuously monitor patients for changes in their conditions. Staff must report changes in patients as situations warrant. When patients’ conditions worsen because staff did not make reports within an appropriate period of time, the issue becomes whether the problem should have been reported earlier.
The law does, however, apply a standard of reasonableness to such situations in recognition of the fact that many home care patients cannot be monitored continuously 24 hours per day. The frequency of staff observations, therefore, is determined by patients’ individual needs, the type of provider, customary practice, physicians’ orders, and providers’ policies and procedures.
Beyond listing the factors that will be considered, it is impossible to establish hard and fast rules for reasonable conduct with regard to monitoring and observation. Determinations of reasonableness in these areas will be made on the basis of individual cases.
Some staff members behave as though their only obligation is to report changes in signs and symptoms to physicians. They are all too familiar with situations in which patients’ conditions changed and were clearly worsening over a period of hours. Patients’ attending physicians may be unresponsive to contacts from staff.
Providers must recognize that they have an obligation to obtain and document a response from patients’ physicians whenever they report changes in patients’ conditions. In other words, they cannot throw reports to physicians down a black hole.
When physicians are unresponsive despite repeated requests for assistance, staff members have an obligation to do whatever is necessary to make certain that patients receive needed care. It may be helpful to involve medical directors or consulting physicians in obtaining needed care.
Providers must establish and monitor a system for making certain that patients’ laboratory results are received on a timely basis and that physicians are notified of the results. It is an unacceptable situation for staff to send work to laboratories and providers are never sent the results.
The system must track lab work from beginning to end. That is, providers must be able to demonstrate through documentation that specimens were obtained and sent to the lab and that results were received in at timely manner and communicated to physicians. If the system of documentation indicates that results are overdue, practitioners have a legal duty to follow up with the lab and to obtain the results promptly. In other words, staff cannot get off the hook by saying that it is the lab’s responsibility to return results promptly.
Patient falls — your liability
Providers are especially vulnerable to claims of liability in the area of falls. The key to avoidance of this type of liability is evidence of adequate precautions by staff in order to prevent patient falls. In Burks v. Christ Hospital, 19 Ohio St. 2d 128, N.W. 2d 829 (1969), for example, an obese patient in severe pain who was sedated to the point of disorientation was placed in a bed with no side rails. It is not surprising that she fell out of bed.
The decisive fact for the court in this case was that the provider had no nursing policies and procedures that outlined appropriate precautions to be taken by staff in order to prevent liability. The court clearly wanted to see written policies and procedures regarding prevention of patient falls and documentation in patients’ charts that staff followed their own internal policies and procedures.
However, the good news concerning falls is that sometimes patients fall and practitioners are not liable in large part due to effective documentation. Such a case is Killgore v. Argonaut-Southwest Insurance Co., 216 So. 2d 108 (La. App. 1968). In this case, there was clear documentation that the patient was alert and able to call for assistance. Documentation also established that she was placed in bed by staff and that the guardrails were in an upright position. The patient fell when she apparently attempted to climb over the rails to get out of bed.
In Killgore v. Argonaut-Southwest, the patient’s suit was rejected by the court. Because of the detailed documentation in this case, the only basis for her suit was that nurses had an obligation to watch her continuously, a contention that was decisively rejected by the court.
Finally, practitioners certainly recognize that their documentation sometimes fails to meet required standards.
Staff responsible for quality assurance or continuous quality improvement are especially conscious of deficiencies in documentation. In view of surveyors’ zero tolerance for deficiencies and the increase in liability suits against providers, the temptation is to fix the documentation after the fact. It is not uncommon for practitioners to approach other personnel to ask them to repair documentation. The temptation to do so without clear evidence of the circumstances under which corrections were made is too great for some staff members.
Providers are reminded that the following rules regarding documentation apply:
• Errors in documentation may be corrected only if one line is drawn through the incorrect documentation. Corrected documentation may be added to the record but it must be dated with the time it was actually written, not when the original documentation was written.
• Erasures and correction fluid may not be used in patients’ charts to correct incomplete or inaccurate documentation of patient care.
• Staff may correct documentation after the fact only if they actually remember the supplemental information they provide. Documentation after the fact of normal findings, therefore, often is suspect. It is incredible to think, for example, that a staff member remembers a patient’s normal blood pressure reading three weeks after it was taken. Supplemental documentation of abnormal findings or unusual events has more credibility.
• Pressure on staff members to supplement documentation outside of these rules is inappropriate and may result in discipline by licensure boards of offending practitioners. Supervisors constantly harp on the importance of complete, accurate, contemporaneous documentation. Staff members tend to tune out at this point because they have heard the same admonitions so many times.
Documentation is one of very few sources of evidence of quality of care. In short, good documentation is often the hallmark of good care.
[A complete list of Elizabeth Hogue’s publications is available by contacting: Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143. Fax: (301) 421-1699. E-mail: [email protected].]
Staff members frequently do the right thing in the course of patient care, but fail to document the quality of care that was rendered to patients. Then, when care is questioned, practitioners are in a much more vulnerable position than they would have been in if the treatment was properly documented.
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