3: Documentation and Litigation

Question 1

Is documentation part of client care?

Answer 1

Yes! Nursing documentation is recognized as an important duty underscoring professional autonomy.

Question 2

How does poor documentation reflect upon a nurse ?

Answer 2

Poor documentation portrays a nurse that is inadequate, unprofessional, & incompetent

Question 3

What are the 9 purposes of nursing documentation?

Answer 3

1. Ensuring continuity and quality of care through communication
2. Furnishing legal evidence of the process and outcomes of care
3. Supporting the evaluation of the quality, efficiency and effectiveness of patient care
4. Providing evidence for research, financial and ethical quality-assurance purposes
5. Providing the database infrastructure supporting development of nursing knowledge
6. Assisting in establishing benchmarks for the development of nursing education and standards of clinical practice
7. Ensuring the appropriate financial reimbursement
8. Providing the database for planning future healthcare
9. Providing the database for other purposes such as risk management and protection of patients’ rights

Question 4

Describe some documentation issues.

Answer 4

• Nursing process (not incorporated)
• Nurse performance (knowledge)
• Daily tasks (direct/indirect patient care)
• Management (support)

Question 5

Describe some hindrances to documentation practice.

Answer 5

• Forms/systems may be inconvenient, redundant, inconsistent, lengthy and time consuming
• Forms often do not reflect amount of nursing care provided
• Forms vary between hospital departments
• Often inappropriate for the workload or responsibilities of clinical nurses

Question 6

Describe some documentation complexities.

Answer 6

• Disruption
• Incompleteness
• Inappropriate
• Nurse confidence & capabilities
• Nursing procedures & workloads
• Inadequate nursing audits

Question 7

What is the mission of the National Practitioner Data Bank (NPDB)?

Answer 7

To protect the public by restricting the ability of unethical or incompetent practitioners to move from State to State without disclosure or discovery of previously damaging or incompetent performance.

Question 8

Define Malpractice.

Answer 8

An intentional act (or negligence) committed by a nurse that causes physical, financial, cognitive, emotional, or psychosocial damage to a patient under their care.

Question 9

Which category of nurses are responsible for the highest percentage of malpractice payments?

Answer 9

Non-specialized RN (62.7%)

Question 10

What are some issues that contribute to liability risks?

Answer 10

• Improper supervision/delegation
• Early patient discharge
• Nursing shortage
• Hospital downsizing
• Increased autonomy
• Advanced technology
• Better informed consumers

Question 11

Define Tort.

Answer 11

1. Area of civil law that encompasses negligence, personal injury, and medical malpractice.
2. A wrongful act that is committed by someone (or an entity) that causes injury to another person or property.

Question 12

What are the 4 areas that must be proven in a case of negligence?

Answer 12

1. Duty
2. Breach of duty
3. Proximal cause
4. Damages or injury

Question 13

What is the definition of negligence, and what does the JCAHO add to the general definition?

Answer 13

• Failure to use such care as a reasonably prudent and careful person would use under similar circumstances.
• JCAHO adds a additional ‘element’:
  Foreseeability

Question 14

When does Duty occur, and when is it owed to a client?

Answer 14

• Usually occurs when the Nurse accepts responsibility for the care and treatment of a patient.
• Duty of care is owed to a patient when the nurse engages in an activity where he/she is under legal duty to act as a reasonable and prudent person.

Question 15

What is Breach of Duty?

Answer 15

• Breach of duty or standard of care is determined by proving an act of omission or commission resulted in damages or injury to the patient.
• Nurse’s care falls below the acceptable standard of care owed to a patient.

Question 16

What is Forseeability (JCAHO)?

What does it not include?

Answer 16

• The nurse has the responsibility to foresee harm and take actions to eliminate the risk.
• The nurse does NOT need to foresee events that are ‘merely possible’; only those that are ‘reasonably foreseeable’.

Question 17

What is Proximate Cause, and how does it relate to healthcare?

Answer 17

• Causal connection must be evident between the breach of duty and the damages or injury that occurred.
• In healthcare, causation builds upon cause-in-fact and foreseeability.

Question 18

List some types of Damages or Injuries.

Answer 18

• Loss love/affection
• Loss nurturance
• Pain & suffering
• Mental anguish
• Loss survivability
• Emotional stress
• Disfigurement
• Loss of wages
• Loss of life enjoyment
• Premature death

Question 19

What are Damages/ Injuries directly related to, and what are the 3 basic types?

Answer 19

• The negligent act of the Nurse defendant

- Types: physical, $, emotional

Question 20

List the Charting Requirements.

Answer 20

• Chronological
• Comprehensive
• Complete
• Concise
• Descriptive
• Legally aware
• Legible
• Relevance
• Standard (abbreviations, symbols & terms)
• Thorough
• Timely

Question 21

What needs to be charted, according to the rules? Elaborate.

Answer 21

Chart EVERYTHING!

• Observations
• Nursing actions
• Patient response to therapy & treatment
• Unusual incidents or omitted treatments
• Safety precautions taken to protect patient
• All attempts to reach the physician
• Reservations about medical orders
• Date & time of each entry
• Patients name & ID number on each page
• Your signature on each entry

Question 22

What could happen if you leave blanks or omit information on charts?

Answer 22

Leaving blanks or omitting documentation could have disastrous results in a lawsuit against you.

Question 23

Describe some charting “don’ts.”

Answer 23

• DON’T make derogatory remarks r/t pt
• DON’T write irrelevant information
• DON’T criticize another practitioner
• DON’T include extraneous information
• DON’T ever use humor or bias statements
• DON’T write MeQuim filed

Question 24

What is the “Witness that never lies, dies or moves?”

Answer 24

The medical record