Documentation, Part 1: Principles for Self-Protection

Preserve the medical recordand defend yourself.

Overview: This article discusses principles
that inform all good methods of charting and
examines an actual court case to illustrate how
adequate documentation can protect nurses
against allegations of negligence and malpractice. Also discussed are the importance of preserving the medical record and mistakes
commonly made in charting that leave nurses
vulnerable to lawsuits.

n 2003 the American Nurses Association

(ANA) introduced its Principles for Documentation,1 based on the ANAs Code of Ethics
for Nurses with Interpretive Statements and
Nursing: Scope and Standards of Practice.2, 3
These principles suggest that documentation systems
must
be designed in consultation with nursing staff so
that the concerns of nurses are addressed before
the documentation system is implemented.
promote a record once, read many times
approach to avoid duplicate recording by different providers.
use ANA-recognized data sets (for example, the
ANAs National Database of Nursing Quality
Indicators, developed in collaboration with the
University of Kansas School of Nursing, which
compiles data on nursing-sensitive indicators,
including patient falls and pressure ulcers, staff
mix, nursing hours per patient day, job satisfaction, and nurse education and certification4).
be readily accessible by nurses and support data
analysis.
encourage nurses to critically evaluate the system
of documentation and patient outcomes.
Its important to understand that these standards of

Kammie Monarch is a nurse attorney and chief operating officer of Sigma Theta Tau International, the Honor Society of
Nursing. Contact author: kammie@stti.iupui.edu.

58

AJN July 2007

Vol. 107, No. 7

documentation arent tied to any specific charting system. Rather, they are general principles that can be
applied to any system an organization adopts. Some
clinical settings, for example, use a paper formbased,
narrative style of charting; others use setting- or unitspecific flow sheets; still others use charting by exception, recording only exceptions to normal findings.
Regardless of the system used, the purpose of documentation, from a legal perspective, is always to accurately and completely record the care given to patients,
as well as their response to that care. (For more, see
Charting the Course, page 59, and The Purpose of
Medical Record Documentation, page 60.)
HARTZELL V. CITY OF WARREN, ET AL.
In civil litigation in which there is alleged negligence
or nursing malpractice, documentation in the medical record can exonerate accused nurses regardless
of their practice setting. Such was the case in
Hartzell v. City of Warren, et al., in which a nurse
who worked at a correctional facility was named as
a defendant.5 The case was decided by the Michigan
Court of Appeals in May 2005.
In this case, Debra Cisco, RN, was one of a number of defendants who was accused of providing
grossly negligent, life-ending nursing care to Robbie
Hartzell. Ciscos documentation of her interaction
with Hartzell, as well as her deposition testimony, led
the appellate court to conclude that she was not
grossly negligent and did not commit malpractice.
Cisco evaluated Hartzell at 9:30 pm on July 27,
1998, at the Macomb County Jail in Mt. Clemens,
Michigan. She measured his blood pressure and
determined that it was within normal and acceptable limits at 132/94 mmHg. She noted that
Hartzell said that, after surgical repair of a cerebral
aneurysm and intracerebral hemorrhage a month
before, hed begun taking 0.2 mg Catapres (clonidine) by mouth twice daily to manage hypertension.
He said that he had no other medical problems that
required immediate attention. Because Hartzell had
not yet been examined by a physician, Cisco
arranged for that to occur the following day.
The next day, July 28, at 12:55 pm, Ernest Bedia,
MD, examined Hartzell and determined that his
blood pressure was 180/108 mmHg. The physician
http://www.nursingcenter.com

By Kammie Monarch, JD, RN

ordered blood pressure monitoring twice weekly;

0.2 mg Catapres and Ecotrin (aspirin) once daily.
The medical record indicated that, according to
the physicians orders, Catapres was given at 3:15 pm
on July 28. The initials of another nurse, Janie
Kushniruk, were on the patients chart, indicating
that she had administered the medication, but
Kushniruk testified that she had not given the medication and had not given anyone permission to
sign her initials on the chart. Hartzell was found
unconscious with a blood pressure of 280/200
mmHg. He died two days later at a nearby hospital. In the lawsuit, representatives of Hartzells
estate alleged, among other things, that Hartzell
had been denied proper medical care, including
medication, an omission that caused his death.
After reviewing the evidence, the appellate court
concluded that neither Bedia nor Cisco was deliberately indifferent to Hartzells serious medical needs.
To support this conclusion, the court pointed to the
documentation submitted by Cisco, concluding that
there was no indication that Cisco, the physician, or
anyone else intentionally denied or unreasonably
delayed treatment. Accordingly, the Michigan Court
of Appeals precluded Hartzells estate from pursuing
its claims against Cisco and Bedia.
This case demonstrates that any interaction with a
patient can result in litigation. Therefore, on even the
busiest days, nurses need to complete documentation
carefully and in accordance with the standards of care
(for more, see Documentation, Part II: The Best
Evidence of Care, page 61). As long as the care provided is consistent with the standards of care, nurses
who follow documentation procedures as described
here will be in a good position to defend themselves
if theyre ever accused of failing to6
assess, analyze, and act according to the level of
care the patient needs.
ascertain the patients wishes concerning selfdetermination.
make an appropriate nursing diagnosis, identify
the patients needs, and implement an appropriate plan of care.
communicate promptly any clinically significant
changes or trends in the patients condition or
responses to interventions.
take appropriate action.
protect patient privacy.
act as a patient advocate.
PRESERVING THE MEDICAL RECORD
Regardless of the practice setting, nurses must preserve the integrity of the medical record in the following ways.
ajn@wolterskluwer.com

Charting the Course

A free online video presentation on different charting methods.

o you have questions about the policies and procedures that govern charting in your workplace? Do
you know whatand what notto chart? Do you know
why its important to document all of the care you provide to patients factually, accurately, completely, and
promptly?
If youre in doubt about the answers to any of these
questions, you might benefit by viewing a free, 30-minute
online video presentation, Charting the Course for
Nursing: Who Benefits When Charting Is Complete?
(go to www.nursingcenter.com/AJNdocumentation). The
video program, supported in part by a grant from the
Nurses Service Organization, explains several methods of
charting and can help you evaluate the method used at
your workplace.James M. Stubenrauch, senior editor

Accurate and complete patient information must

be entered on all paper and electronic documents.
Other diagnostic records and reports, including
but not limited to electrocardiogram, fetal monitor, and other diagnostic recording strips; consultation, laboratory, radiology, and other test
reports; procedure results; and other forms must
be properly labeled, sequentially listed or referenced, and kept with the medical record.
All unofficial papers, such as a nurses to-do list,
must be removed from the patient care area so
they are not included in the medical record.
All documentation practices must be consistent
with the standards associated with the patient
population for which care is being provided.
This applies to both the schedule according to
which documentation is to be performed and the
stylistic conventions and substance of the notations themselves. Any special documentation
requirements for specialty and high-risk settings
must also be followed.
Abbreviations on the Joint Commissions
Official Do Not Use List should not be used
(go to www.jointcommission.org/patientsafety/
donotuselist). Avoid ambiguous abbreviations
such as SOB, which can mean either shortness of breath or side of bed.
Nurses must read medical record entries and
assess the patient themselves before cosigning
another clinicians assessment records.
AJN July 2007

Vol. 107, No. 7

59

The Purpose of Medical Record

Documentation

artzell v. City of Warren, et al. illustrates how the

medical record can be a powerful and persuasive
multipurpose document. The medical record is used for
substantiating the health condition, illness, or presenting concern of a patient.
communicating among health care professionals.
recording the patients response to care.
auditing care for quality improvement, third-party payment, and governmental and regulatory purposes.
conducting research.
resolving competency, disability, guardianship, and
other legal issues.
teaching health care professionals about caring for
patients.

Late entries must be made in accordance with

acceptable organizational standards.
Interventions delineated in critical pathways,
guidelines, policies, procedures, protocols, standards, and care plans must be followed and documented. If a standard recommendation is not
followed, the reasons for this must be documented.
The patients response to interventions and the
clinicians response to a worsening condition or
worrisome indicator must be recorded promptly.
Physicians orders must be transcribed and accomplished as quickly as possible.
Discharge instructions and the patients response
to them must be noted.
Personal, critical, and judgmental opinions concerning health care providers, patients, and family members must not be recorded.
All attempts to contact other health care professionals must be documented, including the time
of the attempt or contact. Do not document any
speculation about why another provider might
not have responded promptly.
Nurses who use paper medical records must also
write concisely and legibly, using correct spelling
and grammar.
use a black ballpoint pen.
draw a single line through erroneous entries to
identify them as erroneous.
use addendum pages as needed in a manner consistent with organizational standards.
60

AJN July 2007

Vol. 107, No. 7

From a legal perspective, documentation-related

challenges arise when there is inattention to or
inconsistency in recording
the date, time, and patients name on each page
of the medical record.
only sequential, factual information, even when
deviations occur (such as when a medication or
other treatment is given later than ordered).
the time at which the assistance of other
providers is requested.
admission data and the patients wishes with
regard to self-determination, using the patients
verbatim responses when possible.
pain intensity, location, accompanying factors,
the interventions performed, and the patients
responses.
steps taken to follow preadministration protocols or policies related to blood, blood products,
chemotherapeutic agents, and other high-risk
infusions or medications.
assessment data, the interventions performed,
and the patients responses, noting deviations
from normal or expected findings and actions
taken in light of those findings.
interactions between the patient and other clinicians.
steps taken to preserve the patients privacy and
to address any related concerns of the patient or
family, including steps taken through the organizations chain of command.
transfer times, modes of transfer, and patient status during and following transfer.
completed treatments, procedures, and interventions, as well as those that have not been completed and the reason they were not completed.
the patients response to medication administration.
REFERENCES
1. American Nurses Association. Principles for documentation.
Silver Spring, MD; 2005 Nov. http://nursingworld.org/
staffing/lawsuit/principlesdocumentation.pdf.
2. American Nurses Association. Code of ethics for nurses
with interpretive statements. Washington, DC; 2001. http://
nursingworld.org/books/pdescr.cfm?cnum=24#CEN21.
3. American Nurses Association. Nursing: scope and standards
of practice. Washington, DC; 2004. http://nursingworld.org/
books/pdescr.cfm?cnum=15#03SSNP.
4. American Nurses Association. National Center for Nursing
Quality Indicators. NDNQI: National Database of Nursing
Quality Indicators. Transforming data into quality care. The
Association. 2004. http://nursingworld.org/quality/ndnqi.pdf.
5. Hartzell v. City of Warren, et al. No. 252458 (Mich. App.
05/10/2005).
6. Monarch K. Nursing and the law: trends and issues.
Washington, DC: American Nurses Association; 2002.
http://www.nursingcenter.com