The Perils and Pitfalls
Of Nursing Documentation
By Judi Kulus
NHA, RN, MAT, RAC-MT, AANAC Master Trainer
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Imagine that it is the year 2013 and you have just been promoted to your dream job at the top-rated care center in town, making more that you ever imagined possible. Life is good! As soon as you settle into your office, you receive a phone call. The call isn’t congratulating you on your promotion, but a call to inform you that you have been named as a defendant in a law suit against the care center you were working for in 2009 – four years ago. Instead of celebrating your promotion, you are being asked to remember what you did (or did not do), on Friday, May 8, between 2:00 and 10:00 p.m. The only information that you have to rely on is the documentation on the resident that you completed that consisted of three general sentences. What do you do?
In today’s litigious
environment the lawsuit will likely
take 11 years of
your life, countless
hours, untold stress
and sleepless
nights, and personal
costs in time and
money. According to
national trending
reports, nursing home litigation is now widely recognized as one of the
fastest-growing
areas of health care
litigation (1).
This means
that charting the
care you provide to
your residents is
critical to showing
the high quality
care you provide.
But this is
easier said than
done, isn’t it?
If I could boil down
the job of charting
to a few key
thoughts, it would
look like this:
Charting
effectively
IS
resident care. Don’t
separate the two in
your mind.
Hurried
charting is poor
charting.
Slow down and
reduce your risk.
Avoid
being sued for
negligence by
implementing the
three
W’s. What happened, what did you do about
it, and what was the
resident’s response.
Resist
practicing beyond
the “scope of
practice” permitted
by law for your
credentials. Know
your state law!
LPN’s don’t do or
chart RN duties.
RN’s don’t do or
chart MD duties.
Time
charting to as close
to the events as
possible. Don’t wait
until the end of
your shift. Chart as
you go!
Henry Ford once
said, “Thinking is
hard work, that’s
why so few do it.”
In nursing practice,
it’s easy to rush,
be careless, make
illogical and
unreasonable
assumptions, and to
just simply not
chart the care we
provide.
Take a moment
to reflect on the
nursing discipline
of “critical
thinking.”
Picture
the entire body of
nursing process that
includes the
standards of
clinical practice,
regulations, ethics,
and reimbursement is
covered with the
umbrella of
“critical thinking.”
GateWay
Community College’s
nursing educator,
Margi J. Schulz, RN,
MSN, describes
critical thinking
as, “The
art of thinking
about your thinking
while you are
thinking in order to
make your thinking
better: clearer,
more accurate, or
more defensible.”
Whether you’ve been
a nurse for six
months or 26 years,
your charting skills
can be honed in and
improved upon.
Take time to
improve your
critical thinking
skills and enhance
your ability to put
that thinking into
the medical record!
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What's Going on at Pathway
Pathway Health Services would like to congratulate consultant Amy Franklin for becoming an AANAC Master Trainer!
Did you miss an audio conference? Visit Pathway’s new Conference library. To see the past audio conferences that are available for purchase,
click here. CD's come with accompanying presentation materials for staff training at your convenience.
Perspectives Audio Conferencing prepared and hosted by Pathway Health Services!
"Staff training made easy"
This is an exciting educational opportunity for the health care community as well as Pathway Health Services employees.
Audio conferences are held 1-2 times every week from 2:00-3:00PM Central. All conferences are “hot” topics related to the needs of our ever-changing health care system with presentations by Pathway’s experienced, highly qualified faculty.
You can register on the Pathway Health Services website at www.pathwayhealth.com, click on Perspectives Audio Conferencing (left side under featured item) to review upcoming educational opportunities.
These conferences will be recorded and available for purchase and independent self-study approximately one week after the scheduled conference.
Perspectives Audio Conferences:
Don't miss the upcoming audio conference!
- Ten Tips for Legal Nursing Documentation
- Faculty: Judi Kulus, MAT, NHA, RN, RAC-MT, AANAC Master Trainer
- May 7th
- Core Elements of a Successful Medicare Team
- Faculty: Cindy Fronning, RNC, CDONA, RAC-MT, AANAC Master Trainer
- May 8th
- Investigations: core components of a thorough investigation
- Faculty: Jan Eakins, MS
- May 12th
- Medicare and the Business Office—An Important Relationship Not to Overlook
- Faculty: Amy Franklin, RN, RNAC, RAC-MT, AANAC Master Trainer
- May 21st
- Environment and the Role it Plays in F-Tag 323
- Faculty: Jan Eakins, MS
- May 26th
- To register go to:
http://www.pathwayhealth.com/classes/pac.aspx
Come see us at these upcoming events!
- IHCA, May 5-7th, Indiana Convention Center, Booth #401
- WASHA Spring Conference, May 5-6th, Ramada, Stevens Point, WI--Presentations by Pathway consultants
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