STEVE M.

ESTEBAN RN,LPT,MSN,MAN
 “ IF YOU DIDN`T
CHART IT, IT WASN`T
DONE”.
INTRODUCTION
The quality of records
maintained by nurses is a
reflection of the quality of
the care provided by them to
patients / clients.
INTRODUCTION
 NURSE (QUALITY OF RECORDS)=PATIENT (QUALITY OF CARE)
 Nurse is ACCOUNTABLE for the STANDARD OF PRACTICE.

RECORD MANAGEMENT/ DOCUMENTATION

(Integral part of Quality Nursing Practice)
Statistics
 “Medication Errors have been reported to be the leading
cause of deaths in hospitalized patients.” (Staubb & Eggli,
2017)
 READABILITY: Prescribing :39(37%),
transcribing:56(53%)and documentation:10 (10%) errors.
 Surgical Dept. of the Inselpital University Hospital of Bern,
Switzerland, 2017.
 1,934 agents (65 cases)=(3.5%)
 Readability: moderate(2%), bad(52%), unreadable (4%)
 Cohen’s Kappa Coefficient: 9.1 (VERY GOOD INDICATOR
OF ERROR)
Statistics
 “Factors that Contribute to Medication Errors in the
Philippine Heart Center,” (Carino, Divinagracia, et. Al,
2017)
 AREA OF ASSIGNMENT & WORKING OVERTIME:
Prescribing (90.8%), order processing (55.7%), dispensing
(92.5%), administering (85.4%)
 Increased workload, high nurse-patient ratio, increased
workload are the leading causes of the error.
 WRITTEN EVIDENCE showing:
Responses to
 Test
 Treatment
Documentation  Procedure

Interaction between/ among

 Healthcare Professionals
 Client/Families
 Healthcare Organizations
•Documentations can be used to determine whether or not the care provided met required
standard.
•Documentation of nursing care includes the plan of care, client goals, client responses to
care, and the registered nurses clinical decision making
•Charting is an integral part of professional patient care rather than something that “takes
away from patient care.” Adequate documentation facilities, good communications can
protect both the patient and the registered nurse
 Purposes of documentation

professional responsibility
accountability Meeting legal and practical
communication standards
education research
reimbursements
Nurses are professionally accountable for
ensuring that any duties they delegate to
members of the healthcare team

Ex. If a student nurse completes nursing

records, then a registered nurse must
countersign the entry, which shows that
they agree with the content.
RECORDING is a method of communication that VALIDATES th
care provided to the client. It should clearly communicate all
Important information regarding the client

 ACCURATE  LEGIBILITY, SPELLING

 CLEAR & GRAMMAR
 COMPREHENSIVE  FACTUAL & TIME-
 COMPLETE SEQUENCED
 HONEST DESCRIPTIVE
NOTATION
 ABBREVIATIONS
Abbreviations Descriptive Notations
Illegible Writing Ideal Charting
Information should be communicated,
FREQUENTLY
Frequency of documentation supports ACCURACY particularly
when precise assessment is required as a result of client
conditions.
TIMELY
Documentation should be done ASAP after an event has
occurred.
CHRONOLOGICALLY
Documenting events in a chronological order in which they took
place is important, in terms of revealing CHANGING
PATTERNS in a client health status.
Enhances clarity of communications, enabling Healthcare
Providers to understand what care was provided
Health care students use the medical record as a tool to learn
About the disease process, complications, medical surgical
Diagnosis and interventions
Documentation is utilized to
determine the severity of illness, the
intensity of services, and the quality of
care provided upon which payment or
reimbursement of health care services
is based.

Ex. An unsatisfied care recipient may

reimburse his hospitalization cost
NURSE’S RESPONSIBILITY

• It is essential that health professional

caring for a patient have current
information about the patient’s
condition, goals and progress

• Registered nurses are responsible and

accountable for their nursing practice
and conduct and they can be held
legally accountable for those actions.
General Guidelines for proper
charting:
1. Charting should be consistent with your employers
written policies
2. If you did it or saw it, you should chart it
3. If you didn’t chart it, you didn’t do it
4. Charting should include any interactions with staff
members or doctors, including failed attempts to reach
them, concerning the care of a patient
5. Do not erase an error or remove pages, draw a line thru
the error, note, it was an error and initial it
6. Records should be clear, legible, accurate and should use
proper terminology
7. Chart chronologically at the time of occurrence or as
soon as possible afterward
8. Charting should be in inked and signed appropriately
General Guidelines for proper
charting:
9. Consider the time and financial cost of inadequate
documentation
10. Avoid duplication
11.Keep charts or flow sheets close to where care is given
12. Review the list of activities you do everyday that can be
done by someone other than a registered nurse, you cant
delegate documentation
13. Ensure that you have the correct client record
14. Document as soon as possible to ensure
accurate recall of data
15. Date and time each entry.
16. Sign each entry with your full legal name
and with your signature
17. Do not leave space between entries
General Guidelines for proper
charting:
18. Use quotation marks to indicate direct client responses
20. Write legibly
22. Document in a complete and but concise manner
Failure to document is a key factor because MEDICAL
RECORD is
a LEGAL DOCUMENT and in case of lawsuit the records
serves as a
description of exactly what happened to the client.

FAILURE!!!!!
LATE/DELAYED
Dependent upon AGENCY POLICY (Clearly defined,
make addendum, individually dated, must be signed by
Nurse involved).
LOST ENTRIES
Dependent upon AGENCY POLICY (may
RECONSTRUCT the entry clearly indicating the
care/event as a replacement for a lost entry.)
 EFFECTS OF INCOMPLETE MEDICAL RECORDS:

COST HOSPITALS REIMBURSEMENT PESOS WHEN THERE IS

NO DOCUMENTATION OF THE SERVICES THAT WERE GIVEN

HAMPER QUALITY ASSURANCE AND RISK MANAGEMENT

EFFORTS.

FORCE HOSPITALS TO SETTLE SUITS OUT OF COURT TO LOSE

CASES BECAUSE LAWYERS CANNOT PREPARE A SOLID DEFENSE

NOTE: 85% OF MALPRACTICE CASES THAT COULD BE

DISMISSED FOR LACK OF EVIDENCE END UP IN COURT
BECAUSE THE PATIENT RECORD IS TOO POOR TO
DEFEND THE HOSPITAL.
1. Medication errors involving Vulnerable patients.
2. Errors resulting from FATIGUE.
3. Errors that can be deemed grossly negligent by a
nursing expert.
4. Errors that can inflame public sentiment.

CRIMINAL NEGLECT/ NEGLIGENT HOMICIDE 10-

14 years to lifetime

Reference: American Nurses Association. Press Release. The American Nurses Association
comments on WI Department of justice decision to pursue criminal charges against RN in
Wisconsin. November 20, 2006.
Rely on clients medical records as a clinical data source to
Determine if clients meet the research criteria for study.
WHAT SHOULD BE DOCUMENTED?
 Environmental factors( safety, equipment), self care,
client education
 Clients outcomes, clients response to treatments, or
preventive care
 Discharge assessment data
 More comprehensive notations to clients who are
seriously ill
 All relevant assessment data, including monitoring
strips
 Information related to any client transports
WHAT SHOULD BE DOCUMENTED
 Collaboration / communication with
other health care providers
 Medication administration
 Verbal orders/Telephone orders
WHAT SHOULD BE DOCUMENTED
 VERBAL/ TELEPHONE ORDERS
 Miscommunication/ lack of
communication may lead to Negative
implications.
 Do`s in documentation
Check that you have the:
 correct chart
 reflects nursing process
 Write legibly
 Chart the time you gave a
medication, the administration
 route, a patient’s response
 chart precautions or preventive
measures used
 record each phone call to a
physician
 Chart patients care at the time
you provide it
 If you remember an important
point after you’ve
completed your documentation,
chart the information
 With a notation
 Document often enough to tell
the whole story
 Donts in nursing documentation
 Don’t chart a symptom such as c/o pain
 Don’t alter a patients record
 Don’t use short hand or abbreviations
that aren't widely accepted
 Don’t write imprecise descriptions
 Don’t chart what someone else said,
heard, felt or smelled unless
information is critical
 Don’t chart ahead of time
 How can a manager help
his/her staff document
better?
 Provide appropriate space for registered nurses to think and
document. Advocate for user-friendly charting policies and
systems that demonstrates nursing accountability and
professional judgment.
 Advocate for point of care charting, such as flow sheets,
medications, administration records, etc.
 Department heads and supervisors to
revise job description so that
documentation responsibilities of all
Professionals are well defined.
Forms used for documentation if they
facilitate or hinder documentation or
recording, revise, if there is a need, evaluate
Sanchez stated:

“We must always stress the

importance of a complete accurate and up
to date documentation because It does
not only project the image of an
efficient conscientious and reliable staff
but more importantly, it gives the
impression to patient that he is being
taken cared of properly”.
• In a mal practice suit, good documentation
in the medical records can be ones BEST
FRIEND OR WORST ENEMY.
• If a claim is not settled and proceeds to
trial, the most important evidence presented
to the COURT is the medical record.
• The COURT uses the medical record as a
legal guide to assess the health care
providers professional conduct to determine
whether they adhered to or deviated from the
standard
• As a preventive liability
tool. If a nurse does not
document the care
provided, treatments may
•
jeopardize the patient
safety.
In conclusion, the nurse documentation is a
legal record that provides information about
the continuity of care from admission to
discharge.

Careful documentation is one of the best

defenses against liability exposure and
provides a supportive record of medical and
treatment interventions and evidence of
quality patient care.
Adaptation of the Electronic Health Record
(EHR) is recommended.
• It is important to remember the basics for good
documentation to protect yourself legally and to be able
to provide good care to your patients.
• Keep in mind, whether your facility uses any type of
documentation systems, you need to document your
actions expertly.
• BY FOLLOWING THESE TIPS AND GUIDELINES,
YOU WILL BE WELL ON YOUR WAY TO
PROTECTING YOURSELF LEGALLY AND
PROVIDE THE BEST POSSIBLE CARE TO YOUR
PATIENTS.
• QUALITY DOCUMENTATION & RECORDING ARE
THE ESSENCE OF A GOOD QUALITY MEDICAL
RECORD HAS ALWAYS BEEN CONCERN IN
HEALTH CARE …… WHY ?
• THE RISK TO HUMAN LIFE
AND WE WILL SAY IT
ONE MORE TIME….

“ IF YOU DIDN`T
CHART IT, IT WASN`T
DONE”.