Legal implications of free-text charting

EmmieRN · Sep 29, 2011

Dudette, I find that our charting system allows for sufficient detail to describe the patient in detail. It also allows for addition of words that are not in a drop down list. (I should maybe add that all of our charting is computerized)

Here is an example of what I'm talking about. This is what I might find in a note:

"Alert and oriented. Medicated for pain twice. Heparin drip infusing. Dressing to abdomen clean, dry and intact. Bowel movement x1".

My problem with this is...I've ALREADY charted all of this. If I use the wrong wording, but this is as much a part of the legal document as my head-to-toe flowsheet (which is not just a one-time flowsheet, it allows for documentation of any changes such as charting pain med effectiveness, bowel movements, dressing changes, and implementation of new orders, etc.), then does my head-to-toe flowsheet credibility come into question if it contradicts my note? Like if I have a blood sugar entered into the chart in real time, and then I write in the note that I gave d50, but accidentally cite the time as 5 minutes prior to the actual blood sugar check, for example. Not sure if this is a good example, but hopefully gives you a better idea of what I'm concerned about here.

evolvingrn, BSN, RN · Sep 29, 2011

We do it, and we are instructed to use grim charting. Those notes are actually evaluated when it comes to audits with medicaid and can be the difference in getting paid or not. Those notes are also what the case managers read daily so its a great way to advocate for your patients. I know that if i put something in the follow up. 'consider evaluating pt for atc pain medication....they will most likely be on it the next shift i work" ect....... my summary usually is focused on addressing any and all symptoms that i managed.

nurse2033, MSN, RN · Sep 29, 2011

You mean the way nurses have been charting since pencils were invented? Nurses notes on paper were free-text. You do want to be sure to write exactly what you mean in a clear way. Actually drop downs are kind of weird...

EmmieRN · Sep 29, 2011

Okay, well let me clarify. I don't have a problem with free-text charting alone and everyone should know how to do it correctly since even the best systems end up having downtimes. My concern is that if I've already charted information in a flowsheet, I don't want to also reiterate the same info in a note that will become part of the chart. I'm happy to write this down important highlights with pen and paper in order to give communication to the next shift and give a nice thorough verbal report, but the double charting worries me.

nurse2033, MSN, RN · Sep 29, 2011

Yes, do not double chart. If you do not double chart perfectly in synch you create a paradox. Legal time and space will slow and twist, cats and dogs will live together, and the undead will walk the Earth. I hate it when chart review wants this. Hopefully you are free texting to cover things that don't fall within the drop downs. If you have already charted something, don't restate it in free text.

beast master RN · Sep 29, 2011

well def dont start free text charting after a bad/rough day . might end up regretting something you put on their , in a" i dont care moment "

Esme12, ASN, BSN, RN · Sep 29, 2011

okay, well let me clarify. i don't have a problem with free-text charting alone and everyone should know how to do it correctly since even the best systems end up having downtimes. my concern is that if i've already charted information in a flow sheet, i don't want to also reiterate the same info in a note that will become part of the chart. i'm happy to write this down important highlights with pen and paper in order to give communication to the next shift and give a nice thorough verbal report, but the double charting worries me.

why not...if you've already charted it then what's the difference. if some thing's wrong then it's wrong throughout.....right? if the facility wants a summary of the day in one paragraph for md's and case workers then you need to comply. i have been a nurse for 32 years and i have "free text" (narrative) charted the entire time. i have double charted when flow sheets came into play because i didn't believe in the validity of a check mark in a court of law to protect me. i have done this with the introduction of computerized documentation and electronic records for 32 years......i have never been sued (well at least not yet....knock on wood... :lol2: )

http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues

with any professional license comes ethical and legal responsibility. doctors take the hippocratic oath pledging to do no harm to patients; lawyers are held responsible for their clients in court; and architects are responsible for the safety of the structures they build. nurses are no different. whether it's administering a medication incorrectly or failing to obtain an informed consent from a pre-op patient, nurses may be held legally responsible if they fail to meet certain standards.

five legal issues in nursing: what every nurse should know

all nurses should be familiar with nursing law and ethics and understand how nursing legal issues can affect them. know your basic nursing laws and avoid lawsuits and liability:

1. signatures are golden

when a physician or other health care provider orders a procedure be done to a patient, it is the nurse's responsibility to ensure an informed consent has been performed and signature obtained(edited for clarity). this means that the patient:

understands the procedure and the alternative options
has had a chance to ask the provider any questions about the procedure
understands the risks and benefits of the procedure
chooses to sign or not sign to have the procedure performed.

if the nurse does not ensure signatures/informed consent are obtained, both the nurse and the operating provider can be held liable for damages incurred.

2. document, document, document

it is the nurse's responsibility to make sure everything that is done in regards to a patient's care (vital signs, specimen collections, noting what the patient is seen doing in the room, medication administration, etc.), is documented in the chart. if it is not documented with the proper time and what was done, the nurse can be held liable for negative outcomes. a note of caution: if there was an error made on the chart, cross it out with one line (so it is still legible) and note the correction and the cause of the error.

click on link.....for 3,4 qnd 5 very good information. http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues

i am of the philosophy...if it isn't documented it isn't done. i have found that facilities that don't like a lot of documentation like to make nurses scapegoats. it has been my experience, when auditing charts, that when a nurse documents in narrative (free text) she leaves huge clues to the real person responsible for a bad outcome. 0115 "md paged again stat (x6)for k of 10.2. 0125 md returned page notified of results....no new orders received. 0145 patient coded see code sheet....."

the key is to be objective and not write in the chart like you post on facebook. "patient is a jerk" should be "patient continues to exhibit agitated, disruptive behaviors and continues to be loud....shouting profanities and staff and visitors calling housekeeper a "f#*%ing b!$&h" and throwing bedpan into hall. md paged."

http://dynamicnursingeducation.com/class.php?class_id=32&pid=17

http://www.ed2go.com/dtccowens-pro/catalog/productdetail.aspx?productid=4789&tab=detail

http://www.infobarrel.com/how-to_conduct_proper_nursing_documentation_in_the_hospital#axzz1zlmvqft0

i hope this helps......:)

psu_213, BSN, RN · Sep 29, 2011

When a physician or other health care provider orders a procedure be done to a patient, it is the nurse's responsibility to obtain an informed consent signature.

I take a bit of exception with how this one is worded...As a nurse, I make sure infomred consent is done, the signature completed, etc. If I do something that requires consent (such as giving blood) and the consent is not done, then I am one the line as much as the doc. However, it is not my place to explain risks/benefits to the pt. Even though I may know the risks/benefits of, for example, a transfusion, the doc (NP, PA) must actually get explain this to the patient and get the consent.

As for the OP, if there is something not covered by the charting system (the check boxes or the dropdowns) then I will definitely free text it. I will also write a free text note explaining the general conditon of the pt: something to the effect of "sleeping in bed, easily arousable, no visible distress (if that part is true ), family at BS/no family present, call bell explained and within reach." I will not double chart anything in the 'structured' assement (checkboxes, etc), the VS flowsheet, the eMAR, etc....there can be legal entanglements from this.

Esme12, ASN, BSN, RN · Sep 29, 2011

i take a bit of exception with how this one is worded...as a nurse, i make sure informed consent is done, the signature completed, etc. if i do something that requires consent (such as giving blood) and the consent is not done, then i am one the line as much as the doc. however, it is not my place to explain risks/benefits to the pt. even though i may know the risks/benefits of, for example, a transfusion, the doc (np, pa) must actually get explain this to the patient and get the consent.
as for the op, if there is something not covered by the charting system (the check boxes or the dropdowns) then i will definitely free text it. i will also write a free text note explaining the general condition of the pt: something to the effect of "sleeping in bed, easily arousable, no visible distress (if that part is true ), family at bs/no family present, call bell explained and within reach." i will not double chart anything in the 'structured' assessment (check boxes, etc), the vs flowsheet, the emar, etc....there can be legal entanglements from this.

actually..it's not my quote but one from an article. whether or not the nurse signs depends on where you work and what policies are in place at that particular facility.

http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues

when a physician or other health care provider orders a procedure be done to a patient, it is the nurse's responsibility to obtain an informed consent signature. this means that the patient:

understands the procedure and the alternative options
has had a chance to ask the provider any questions about the procedure
understands the risks and benefits of the procedure
chooses to sign or not sign to have the procedure performed.

if the nurse does not obtain signatures, both the nurse and the operating provider can be held liable for damages incurred.

whether it is the nurses responsibility obtain the signatures or not it is the nurses responsibility to ensure the patient has knowledge of the highlighted items.....and that the md has done their job to explain to the patient. many facilities have nurses still sign the consents after they have been signed as witness that they have personally questioned the patient and that the patient understands and acknowledges that the md has explained everything to them. you are witnessing the the patients understanding and that the md, surgeons, and anesthesia have fulfilled their obligation under informed consent.

Altra, BSN, RN · Sep 29, 2011

I have found that facilities that don't like a lot of documentation like to make nurses scapegoats. It has been my experience, when auditing charts, that when a nurse documents in narrative (free text) she leaves HUGE clues to the real person responsible for a bad outcome. 0115 "MD paged again stat (x6)for K of 10.2. 0125 MD returned page notified of results....no new orders received. 0145 patient coded see code sheet....."

Very, very true, in my experience, too.

The quality of any check box charting varies widely. In better systems, the software provider has worked closely with the medical, nursing and legal staff of the health care facility, and all are in agreement on wording/descriptions of procedures, assessments, etc. This doesn't always happen.

I use narrative/free text notes to "paint the picture of the patient" (to use the old-school term ... ), to document evolving situations that I think could go badly as Esme12 described above, and to document conversations with patients/families so that it is clear who was made aware of what, when. I do find it necessary to sometimes "double chart" things in a narrative note -- again, for clarity, when I feel that the check box/drop down menu isn't sufficient to convey what I what to record about a situation.

OP, I probably would object to the practice you describe -- of writing a kind of summary note at the end of the shift in order to communicate with the oncoming nurse. Unless it is labeled as a "shift summary" or something like that, I do agree that it is open to misinterpretation because it is describing events that may have occurred over 8-12 hours in one timed note. You've said that the practice isn't mandatory, however, so it would appear that you are free to not do this.

I would also be willing to bet big money that somewhere back in time -- this practice originated on your unit when Nurse A was unable/unwilling to communicate with Nurse B to give a concise, effective hand-off report. :rolleyes:

Altra, BSN, RN · Sep 29, 2011

Five Legal Issues in Nursing: What Every Nurse Should Know
All nurses should be familiar with nursing law and ethics and understand how nursing legal issues can affect them. Know your basic nursing laws and avoid lawsuits and liability:
1. Signatures Are Golden
When a physician or other health care provider orders a procedure be done to a patient, it is the nurse's responsibility to obtain an informed consent signature. This means that the patient:
Understands the procedure and the alternative options
Has had a chance to ask the provider any questions about the procedure
Understands the risks and benefits of the procedure
Chooses to sign or not sign to have the procedure performed.
If the nurse does not obtain signatures, both the nurse and the operating provider can be held liable for damages incurred.

I disagree with the quote above, and I think it's important to recognize that the source is an "article" from a commercial company which provides various multimedia educational resources for nurses and other health care professionals -- not a legal authority such as a state board of nursing from which legal scopes of practice are derived.

There are variations among state nurse practice acts regarding informed consent. And it is my strong plea to ALL NURSES: KNOW THEM! I agree, Esme12 -- it is every nurse's individual responsibility -- without exception!

My state's nurse practice act, which is vague on so many things, is actually quite crystal clear when describing informed consent -- that it is the responsibility (in this state) of the physician/provider who is ordering/performing the test/procedure, and that an RN MAY NOT "obtain" consent.

A hospital or other employer may require that a nurse check that all consents have been obtained ... but this is not the same as obtaining consent.

BuckyBadgerRN, ASN, RN · Sep 30, 2011

why not...if you've already charted it then what's the difference. if some thing's wrong then it's wrong throughout.....right? if the facility wants a summary of the day in one paragraph for md's and case workers then you need to comply. i have been a nurse for 32 years and i have "free text" (narrative) charted the entire time. i have double charted when flow sheets came into play because i didn't believe in the validity of a check mark in a court of law to protect me. i have done this with the introduction of computerized documentation and electronic records for 32 years......i have never been sued (well at least not yet....knock on wood...)
http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues
with any professional license comes ethical and legal responsibility. doctors take the hippocratic oath pledging to do no harm to patients; lawyers are held responsible for their clients in court; and architects are responsible for the safety of the structures they build. nurses are no different. whether it's administering a medication incorrectly or failing to obtain an informed consent from a pre-op patient, nurses may be held legally responsible if they fail to meet certain standards.
five legal issues in nursing: what every nurse should know
all nurses should be familiar with nursing law and ethics and understand how nursing legal issues can affect them. know your basic nursing laws and avoid lawsuits and liability:
1. signatures are golden
when a physician or other health care provider orders a procedure be done to a patient, it is the nurse's responsibility to obtain an informed consent signature. this means that the patient:
understands the procedure and the alternative options
has had a chance to ask the provider any questions about the procedure
understands the risks and benefits of the procedure
chooses to sign or not sign to have the procedure performed.
if the nurse does not obtain signatures, both the nurse and the operating provider can be held liable for damages incurred.
2. document, document, document
it is the nurse's responsibility to make sure everything that is done in regards to a patient's care (vital signs, specimen collections, noting what the patient is seen doing in the room, medication administration, etc.), is documented in the chart. if it is not documented with the proper time and what was done, the nurse can be held liable for negative outcomes. a note of caution: if there was an error made on the chart, cross it out with one line (so it is still legible) and note the correction and the cause of the error.
click on link.....for 3,4 qnd 5 very good information. http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues
i am of the philosophy...if it isn't documented it isn't done. i have found that facilities that don't like a lot of documentation like to make nurses scapegoats. it has been my experience, when auditing charts, that when a nurse documents in narrative (free text) she leaves huge clues to the real person responsible for a bad outcome. 0115 "md paged again stat (x6)for k of 10.2. 0125 md returned page notified of results....no new orders received. 0145 patient coded see code sheet....."
the key is to be objective and not write in the chart like you post on facebook. "patient is a jerk" should be "patient continues to exhibit agitated, disruptive behaviors and continues to be loud....shouting profanities and staff and visitors calling housekeeper a "f#*%ing b!$&h" and throwing bedpan into hall. md paged."
http://dynamicnursingeducation.com/class.php?class_id=32&pid=17
http://www.ed2go.com/dtccowens-pro/catalog/productdetail.aspx?productid=4789&tab=detail
http://www.infobarrel.com/how-to_conduct_proper_nursing_documentation_in_the_hospital#axzz1zlmvqft0
i hope this helps......:)

ok, we were taught very differently: getting the consent form signed--we can verify that it has been signed, but in no way, shape or form is the nurse supposed to explain the procedure, answer questions, etc. that is for whomever is performing the procedure to do!!!