Legal Aspects of Documentation

In this lesson, we’ll look why we document and how the laws can affect documentation.

When we look at a documentation, the first thing that I want to stress is that your documentation is part of the patient’s medical record. The patient will always be able to see what’s written. The importance of that a patient can see if the care that was given to them was accurate, and also to see how they were cared for.

The other thing about documentation is that it’s a way for healthcare providers to communicate to one another. So a doctor can review when a foley was pulled, what was found during an assessment, what a wound looks like or other findings. This helps to reduce delays in care.

When you document, it’s important that you document as close to real time as possible. The main reason that you want to do this is because if you wait to chart something that you did, you may not be able to remember it accurately.

If you chart exactly what you did at almost the same time that you did it, you’ll avoid putting in inaccurate information in the chart.

There’s some great info in the lesson on documentation basics and also pro-tips that outline ways to help you remember information if you can’t do it right then and there. But, best practice is always to document in real time whenever possible.

When we talk about documentation, there’s a lot of focus on the things that you SHOULDN’T DO.

So here are some examples.

First, don’t chart in advance. That’s not truthful. You can’t exactly predict what’s going to happen with your patient, so you need to chart, retrospectively, or after it happened so that you can put down what really happened with your patient.

The other thing that you can potentially do by charting in advance is that you inaccurately record something, say that all of your IVs are patent. Then let’s say, one of them fails, and you need to replace it. You get it a new one placed, but forget to change the charting. The new nurse comes on shift and realizes that it’s incorrect; you’ve just falsely documented care.

The other thing you don’t want to do is chart under someone else’s log in or name. It’s misleading in that one nurse provided care to a patient and documented as if someone else did it. It’s similar to forging a signature on a check. Don’t do it.

Another thing you want to avoid is changing someone else’s documentation. The onus is on you to document the care you provide, as is the care that other nurses do. Just because your friend didn’t document that certain care was done, you shouldn’t take up for them. Because if something happens to the patient as a result of their care, and you’ve covered for them by changing their documentation, you put liability on yourself. Don’t do it, it’s too risky.

One of the big things we want to focus on here is some of the legal implications of documentation. Like, exactly how documentation plays in the grand scheme of the law.

First, and foremost, is the use of medical records in lawsuits. Sometimes medical records are presented during a lawsuit to prove a point that care wasn’t provided. You want to make sure that the care you provided is meticulously charted. You don’t want to be hung out to dry because you forgot to document the turn that one patient and that bed sore on her leg turned into an amputation, and she decided to sue the hospital.

Audits is another reason for documentation. Hospitals will commonly make sure that everyone is scanning their patients and their meds and turning and documenting pain, etc. By charting it, you show that you provided that care, and that you’re following policy.

The last point to make here is that documentation and charting can be subject to review by The Joint Commission and CMS. In the legal lesson, we talk about how The Joint Commission and CMS can shut down hospitals for not complying with their regulations. Where do you think they get that info from? Exactly, medical records. So make sure that you follow the policy of your hospital regarding Joint Commission and CMS documentation.

Now to recap:

Your documentation is a reflection in the patient’s medical record of the care you provide, so be truthful and remember that the patient can see it.

Make sure you document in real time so that you can avoid errors and omissions in what care you actually provided.

Be truthful – don’t chart in advance, under someone else’s name or go change someone else’s charting. Be responsible for your own charting, and make everyone else accountable for theirs.

Remember, medical records can be reviewed in lawsuits and audits, so make sure that your charting is accurate.

Also, Joint Commission and CMS check medical records for compliance, so follow those policies.

That’s it for this lesson. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!