Documentation is your friend.

[AngelfireRN]

Boy, that statement has never been more true than this week.

I have been called on the carpet I don't know how many times since I started work at my soon-to-be-former job about my documentation. No, not because of the lack of it, but because Doc felt I 'wrote too much' and 'wasted paper'. Well, I ignored the edict and kept right on documenting everything, from anecdotes about what the patients were going through, to notes about a potential problem with prescription abuse, to noncompliance.

And three times this week alone, it's saved our butt.

I was sent home sick the other day, running a fever, and I came back in to see a chart on my desk, waiting for me to enter it into our database of deceased or dismissed patients. The patient had died, and he was not that old. No one knew what happened, but there had been mention of a lawsuit based on poor medical care. My OM and the office staff had reviewed the chart, and noticed that, every time he was seen, his B/P was to the moon, and always, always, he had not been taking his meds, not taking them correctly, or engaging in other behavior that could compromise their effect. Almost every time, I adjusted the meds, and every time I did, I wrote for him to return in a week for a recheck. He never did. Referral to cardio? He never went. All documented.

Another man is currently involved in a suit regarding a surgery. The last time he took it upon himself to just show up without an appointment ( not uncommon at my clinic), he brought along an 'advocate', and proceeded to request bloods be drawn for some very odd tests, that required special tubes and processing. We did not have the necessary supplies, and he was told that we would at his next scheduled appointment. He then said that he did not want the bloods to go through our dedicated lab, due to an issue with the surgery and the suit. Well, that issue wasn't debatable, and he was told that.

On his appointment date, he refused the bloods, and said that they had already been done. I documented as much, and when he called today to request an Rx for those tests, we had him dead to rights. No room to try and say that we just didn't do them, as he asserted.

And lastly, the patient who consumed 1 and 1/2 month's worth of meds in 3 weeks or less, tested negative for her prescribed meds, and positive for meds not prescribed by us. She asserted that she 'had told us and told us' that the meds weren't working, and so she self-adjusted, took more than double her prescribed dose, and then bought more meds off the street. She was told we could not see her anymore.

Thanks to my 'anal' chart notes, we could prove that the abuse of meds had been ongoing, by the patient's own admission, and that she had been counseled. We had documentation that she complained of no increase in pain, and that she had refused treatment and referrals for her 'nerves'. In short, nothing was good enough, unless it was an excuse to complain.

I remember being taught in school about charting, and I never really gave it a lot of thought at that time. Now, however, I'm glad I learned that. I am SO glad that I stuck to my guns and kept charting everything. Just wondering, has charting ever saved your rump?

Thoughts?

[nurseprnRN, BSN, RN]

i review medical records for legal work and i want to tell ya how very important nursing notes are, in large part because they are timed and timely. physicians rarely document the time of their notes, so it's hard to know when they knew something and acted (or didn't act) upon it. they often round in the morning and are charting on yesterday's news, too. nursing notes are the most current, generally speaking.

please, please, please always use complete sentences, work on making your notes legible, because you can never know when someone like me will be reading them.

the cases i'm working on now occurred in 2007, 2004, and 2008. will i be able to tell what happened from your charting three, four, five, eight years from now? i hope so, because it could make a huge difference.

another thing to remember is that insurance companies are looking harder and harder to prevent reimbursing hospitals for care given (and a good hunk of that money goes into your paychecks, folks). the criteria they use often include estimated hours of nursing care, patient teaching, and discharge preparation, and if there's no documentation that a patient got as much attention and care as you know they did, the claim will be denied. the appeals process is long and generally unsuccessful because the payor source holds all the cards-- they run the appeal, they decide on it, and when they say it's done, it's done, and that's the end of it. good clear nursing documentation can help a lot here.

[imintrouble, BSN, RN]

I'm not as good at documentation as I should be.

The only thing I absolutely chart in depth is the conversations I have with Drs.

What we discussed, when we discussed it, who was a witness, and what was the result.

It has been my experience that an MD will throw a nurse under the bus quicker that any pt trying to get malpractice bucks.

[maelstrom143]

Nothing as dramatic, but I have had a few notes that backed me up. We had a patient fall and attempted to call family 4 times. I charted each attempt and result. When family arrived in AM they swore up and down that no one had called and phone had not rung. In front of them I pulled up the eChart and showed them each attempt. That was the end of that.

Also have had patients claim that they did not receive pain meds or that they have not seen anyone in "hours" to which I can usually open up the chart while in their room, quote the exact time I was in, and what occurred, as well as their response. I love the look on their faces as they quit complaining and say, "Oh...I forgot."

Priceless