Best Practices in Nursing Documentation

Nursing documentation facilitates continuity of care between providers and supports clinical decision making.  Medical record documentation impacts many aspects of healthcare, including, but not limited to, quality of care, patient outcomes, reimbursement, accreditation, and legal actions.  The Ohio Health Care Association recently provided a seminar on Nursing Documentation to Support Services and Care Delivery to address these issues.

Documentation – Quality of Care, Reimbursement and Accreditation

The American Health Information Management Association states that “for documentation to be meaningful, it must be clear, consistent, complete, precise, reliable, timely and legible.  This is necessary to accurately reflect patient acuity and complexity, severity of illness, risk of mortality and scope of services and resources provided.”  AHIMA also notes that electronic health record (EHR) functions such as cut and paste, templates, and other tools can enhance documentation, but improper use can diminish documentation integrity.

Government agencies, such as the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) employ quality measures based on medical record documentation which is used for public reporting and reimbursement.  CMS medical reviews include the collection and clinical reviews of medical records and other information to ensure payment is made only for services that meet billing and medical necessity requirements.  As discussed previously in this blog, data is published by Medicare on Care Compare, the Five-Star Quality Rating System for nursing homes, and by the Joint Commission Quality Check.  Much of this publicly available data is based on reviews of documentation in the medical records.

Documentation – Risk Management

Recent examples of plaintiff verdicts of $30 million and $19 million underscore the importance  of quality documentation from a legal perspective.  Terri Lightner, BSN, JD, Manager, Clinical Operations at Excelas recently attended the OHCA seminar where Sherry Thomas, BS, RN, QCP, IPCO, Director of Clinical Services for LeaderStat identified common nursing charting errors, what constitutes strong documentation, and recommendations for best practices in nursing documentation.

Strong documentation by nursing staff includes a complete record of:

  • Failing to record:
    • pertinent health (vital signs, weights, blood sugar) and/or drug information
    • nursing actions
    • medication administration
    • discontinued medication(s)
    • drug reaction(s)
    • changes in the resident’s condition
  • Ensuring data is recorded in the appropriate resident’s medical record
  • Transcribing orders properly
  • Legible handwriting

In addition, it is imperative that the documentation in the medical record reflect that staff are following the facility’s established policies and procedures and that each resident’s care plan is being implemented.  The facility’s policies and procedures should be clear, and not exceed state and federal requirements.

Documentation – Best Practices

Clinical documentation must accurately reflect the resident’s condition(s) and quality of care.  As noted previously, keys to quality documentation include:

  • Legibility
  • Completeness
  • Clarity
  • Consistency
  • Precision
  • Reliability
  • Timeliness

Nursing experts stress documentation should be factual, specific, quantified, and based on the patient’s behaviors.  Completeness includes all condition changes, treatments/interventions, resident responses, and communications/training with the resident, family, and other care providers.  When notifying other providers of a change in the patient’s condition, the full name of the provider, exact time of notification, specific data reported (lab result, symptom), the response from the provider, and any orders/no orders must be documented.  All entries must include the date and time; if utilizing an EHR there must be clear notation if referring to an earlier event.  “Chart as you go” is imperative for communications with other healthcare professionals as well as accuracy.  Purposeful nursing documentation focuses on the resident’s concerns and response, as well as the work that the nurse provides through care, education, and psychological support.

Short staffing situations in long-term care are placing unprecedented demands on nurses and other providers in all areas, including time spent charting.  The main vehicle to tell the resident’s story, and the story of the care provided, is through medical record documentation.  A review of the entire patient/resident record can reveal data points to completely describe staff interactions.  For example, a gap noted on a Turning and Repositioning Log may be fully documented on a Nursing Progress Note.  Identification of these perceived gaps through documentation audits facilitates staff training opportunities.

Excelas has the tools and the expertise to assist long-term care facilities in conducting audits, assessing documentation quality and completeness, integrating facility policies and procedures with individual resident medical records, and preparing comprehensive analyses for facility administrators, risk managers, insurers, and counsel.  Tools used by Excelas’ clients to assess documentation include:

  • Provider of Care Report which provides a quick review of all staff who documented in the medical record, the date care was administered, and a hyperlink to the page in the record where the entry was documented.
  • Care Calendar/TouchChart which is a customizable, interactive calendar of all nursing interactions.

Contact Excelas today to discuss how we can support your clinical documentation program through our powerful analysis tools.

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