The adage “If it’s not documented, it’s not done” is routinely taught to nurses, physicians and other aspiring clinicians. That sound advice can make the difference in the outcome in negligence or wrongful death causes of actions, State disciplinary board or licensing actions, Centers for Medicare & Medicaid Services (CMS) enforcement actions and/or federal False Claims Act prosecutions. Because patient/resident medical records are legal documents that are routinely admitted as evidence in court proceedings, accuracy and documentation protocols are vital to maintaining complete records and managing risk.
As an experienced litigator, previously for CMS and currently for healthcare organizations, I know that virtually every case ultimately turns on the documentation that either exists or should have existed. Apart from the fact that accurate and thorough charting provides for quality care, it also offers a shield to protect practitioners from allegations of negligence or other forms of wrongful actions or omissions.
Clear, accurate and complete documentation in a patient’s/resident’s medical record is essential for providing safe, efficient and quality care. Both quality improvement and risk management are enhanced by proper documentation. Additionally, documentation—or the lack of proper documentation—most likely will play a critical role in legal proceedings initiated by residents, their estates or state and federal governmental agencies.
The following is an illustration of why appropriate documentation makes a difference:
A nurse may add to a chart: “Mr. Smith complained of chest pain at 10:30 a.m.” But the preferred clinical note would be: “10:30 a.m.: Mr. Smith complained of dull chest pain that began about 10 minutes ago. Patient denies pain in arms, jaw or elsewhere. Vital signs taken, B/P: 120/64. RR: 18 and unlabored, heart rate, 72, regular. Dr. Jones notified at 10:42 am. No new orders given. Will monitor and continue to report any changes to nursing supervisor.”
If the hypothetical Mr. Smith had died soon after the first note above and a negligence case went to trial, how could the nurse answer questions about the incident two or three years later at a deposition or cross-examination? Attorneys will surely as: “What did you do after Mr. Smith complained of chest pain? Who, if anyone, did you contact? At what time? What were Mr. Smith’s vital signs?” And, the coup de grace from an unfriendly attorney at an even unfriendlier deposition: “Isn’t it true that the standards of documentation for nurses require a more detailed clinical note than what you wrote?”
The take-away from the above is that a clinician should never chart “chest pain” without also documenting what was done about it, who was contacted and what interventions were implemented, including the times of and results of those interventions. More importantly than the legal consequences, adequate charting is essential for providing quality patient/resident care.