Posts Tagged ‘Healthcare Charting’

Use of Technology in Nursing

September 16, 2008

I agree with the person who said much of nursing notes and documentation not being looked at by doctors. It seems like a lot of our charting is overlooked or not even looked at period. It seems that it should be a lot safer and practical for everything to be computerized, including medication reconciliation sheets, but it is often not checked carefully and errors do occur because time is not taken to look over the notes and information collected by the nurse. It is true that nurses are responsible for more and more paperwork or charting, which takes more and more time away from our bedside care. Even though the physicians do not look at my charting, it is important to chart thoroughly and diligently because it can and will be looked at in the event of a lawsuit or legal action.


Documentation of our assessment

August 20, 2008

In this era, it seems as if everyone is sue happy. Documentation of our assessment is vital for assuring a court of law that we did something. In 2008, CMS has passed a law that they will not pay a hospital when a patient develops a bed sore or a urinary infection while hospitalized for something else. My institution has learned the value of documentation. If we fail to chart that a bedsore already existed on admission, we will not be paid. This is really an eye opener for the admission nurse. Sometimes a nurse in a hurry would not turn the patient over and examine their back side. We do a thorough exam now. It must be documented and noted or it essentially was never done in a court of law.


Documentation of Bedsores

July 16, 2008

Joint Commission and CMS (Medicare) have set a Patient Safety Goal of not allowing bedsores to occur during hospitalizations. My institution uses technology to document existing wounds at the time of admission assessment. We are a totally computerized charting hospital. When we identify an existing wound, we bring up a screen of the body and insert a photo of the wound into the patient’s medical record. This feature allows us to prevent lawsuits and receive the correct reimbursement of that patient’s hospitalization. Health assessment no longer has to rely on a verbal or hand written dictation to describe history and physical assessments!


No Harm No Foul: If Nobody Gets Hurt, Is it an Incident?

September 11, 2007

In the book HEALTH PROMOTION THROUGHOUT THE LIFE SPAN, by Carole Edelman and Carol Mandle. Mosby, Inc. Chapter 3 discusses medical errors and refers to the 1999 Institute of Medicine (IOM) research study, To Err is Human: Building a Safer Health System. I had also read an article in OUTCOMES MANAGEMENT titled An Innovative Method of Collecting Adverse Event Data and was very intrigued by both of the articles. So, I conducted my own study at the small, rural community hospital that I am employed. I had noticed that only a small percentage of medical errors were being filed as incident reports and I wanted to know WHY. I made up an Anonymous Adverse Event Survey Questionnaire. For 10 days, one was given to every nurse at the beginning of each shift and to be returned in a plain brown envelope at the end of each shift to keep it anonymous. Over the years, I had heard a lot of grumbling that “Management doesn’t do anything with the incident reports anyway” so I had included that in the 11 reasons for not filing an incident report. The results were amazing. Of the 281 surveys handed out 209 were returned (74%). Of the 209 returned, 130 (62%) reported no adverse events and 79 (38%) reported adverse events. However, of 79 that reported adverse events, only 17 (22%) filed incident reports. That leaves 62 (78%) that did not file incident reports. The most commonly reported reason 21, answered no harm sustained (34%). Nurses that did not think it was an incident 14 (23%). Seven nurses (11%) thought an incident report was not necessary because they informed the nurse involved. Six (10%) did not think that the incident report is used by management as a tool for improvement. Four, (6%) did not want to take the time to file an incident report. Four, (6%) believed it was a waste of time because nothing is done with the reports. Three (5%) answered none of the above and wrote an explanation. Two (3%) feared retaliation from the nurse involved. One (2%) did not know how to use the computer incident form. Zero (0%) feared getting too many incident reports in their file. I added the first 2 reasons together, no harm sustained and did not think it was an incident to equal (57%). That is (57%) did not think they were incidents to be reported, yet according to the returned surveys 14 were medication errors and 4 were patient falls. So, the major barrier to make our healthcare system safer continues to be the question of what constitutes an error, adverse event and incident. (The complete survey report available upon request.)


Forensic Nursing And Charting

August 22, 2007

Documentation in the nurse’s notes is essential in evaluating patient care and outcomes. It is a legal document and will be used in a court of law if a lawsuit is initiated by a patient or family member.

The Forensic Nurse uses nurse’s notes as a means to obtaining evidence in court pertaining to the patient involved. As I read through the “Basic Pharmacology for Nurses” textbook, it is evident in each chapter that charting is documented proof of patient care. Evidence of patient care and treatments, outcome of treatment, health teaching and effectiveness of teaching needs to be documented. We learn this all in nursing school.

Marianne DeMilliano BSN, JN describes “Eight Common Mistakes to Avoid when Charting” which is available at

These mistakes can be avoided and definitely will help a nurse if she ever winds up in court.

With regards to Pharmacology and Nurses, the sixth right of medication preparation and administration is “Documentation”. As discussed in one of my previous posts called “Medication Errors”, documentation of date, time, drug name, dose, site and route of administration is important. Further documentation is required in the nurse’s notes to indicate a patient’s response from the medication. Was the drug effective? Did the patient exhibit any adverse effects (psychologically or physiologically) from the drug? Was there any reaction to the site where the drug was administered? Is the patient’s level of pain pre and post medication documented as per a pain level scale? Was the physician notified of the patient’s response to the medication? Did the physician assess the patient and change the medication order? When a new medication was administered, what was the effect of the medication?

Failing to record nursing actions and failure to record reactions or changes in the patient’s condition is just one of many mistakes Marianne DeMilliano discusses in her article. Other mistakes she notes is failing to record pertinent health or drug information, failing to record that meds have been given, recording on the wrong chart, failing to document a discontinued medication and transcribing illegible or incomplete orders.

Nurse’s notes will aid the Forensic Nurse in obtaining specific content relevant to evidence required for investigational purposes and for use in a court of law.

Forgetting to document patient information means “If you didn’t chart it, it didn’t happen”.


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