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Practice Breakdown: Clearly Communicating Patient Data and Clinical Assessments

Kathy Malloch

Linda Patterson

Vickie Sheets

Karen Bowen

ISSUES IN NURSING DOCUMENTATION

Health care requires good teamwork. Nursing care can never occur in isolation. Communication is central. Written documentation and clear presentations of “making a case” for patient intervention are core competencies of nurses. Perhaps nowhere is system design more important than in documentation. A system must be designed with the goals of the practice of all health care team members, the patient’s well-being and safety, and in the context of the actual work environment. A good system of documentation can improve practice, while a poor one may hinder practice.

The purpose of documentation is to clearly communicate the condition of the patient as well as the assessment, planning, implementation, and evaluation work of nursing. It is a continual and ongoing process that reflects the changing needs and conditions of the patient. Documentation is the critical and sometimes only form of communication among all health care providers about the current condition of a patient.

Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized. Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways ( Meiner, 1999 ). Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase. At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.

As patient care becomes increasingly complex, the importance of timely and accurate documentation becomes increasingly important. Delays, omissions, and errors in documentation may result in delays or errors in assessments, interventions, treatments, procedures, and medication administration. These errors often create a cascade of events that may negatively impact patient care or patient outcome.

DOCUMENTATION OF THE FUTURE

The written documentation record will increasingly appear in the form of an electronic record. The structure, organization, and retrieval of patient data must be user friendly and secure, and should be designed with the workflow of those documenting their patient care in mind. Computerized documentation systems are more than automation of existing paper forms. State-of-the-art documentation systems are designed to more closely reflect the flow of patient care processes in an orderly way and to increase patient safety within the available features and design. Computerized clinical documentation systems that support functional requirements contribute significantly to patient safety and caregiver effectiveness.

Significant advantages for safe patient care can be realized as electronic systems are implemented across the country. Safe nursing practice is supported in the following ways with an electronic record that includes:

· 1Design of documentation systems that more closely reflect actual work processes and patient throughput, supporting clinician assessments and work organization

· 2Integration of physician order entry, medication administration, and clinician documentation systems

· 3Inclusion of a framework that encompasses nursing knowledge functions as a cognitive map for clinicians (nurses handle large amounts of data and often experience overload and stress; also provides professional support in making complex clinical decisions) and increases efficiency ( von Krogh et al., 2005 )

· 4Integration of standards-based organizing frameworks such as Nursing Interventions (NIC), Nursing Outcomes (NOC), and North American Nursing Diagnosis Association (NANDA)

· 5Use of a complex and comprehensive database for patient and nursing research

· 6Inclusion of alerts, popups, and protocols to guide caregivers in both care processes and documentation

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

· 1Elimination of illegibility

· 2Minimized duplication

· 3Improved response time to patient requests

· 4Simultaneous, real-time access to up-to-date patient data for multiple clinicians

· 5Improved documentation completeness

· 6Increased compliance with regulatory requirements (e.g., assessments for pain level, skin integrity, and fall risk)

Users often develop “shortcuts” and “work-arounds” for a poorly designed system of documentation that does not take into account the workflow processes or the time required for documenting. For example, if there are rigid rules for documenting the administration of medications within one-half hour of administration, and the patient-to-nurse ratio is too high, the nurse may be tempted to document before actually administering the medication. This sets the patient up for undetected “missed doses” of medication. Also, if the workflow and patient care record are poorly designed, requiring excessive amounts of time for access, then nurses may not have a chance to document their assessments and treatments in a timely manner. Nondocumented therapies place patients at great risk for second doses of narcotics, sedatives, or other medications.

The importance of documentation becomes apparent following reviews of incidents in which a patient has been affected negatively. Not surprisingly, documentation is rarely the primary error. The down side of the extensive requirements for documentation in today’s complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses’ availability to provide direct patient care has been shown to diminish patient safety ( Korst et al., 2003  Pabst et al., 1996  Page, 2004 ).

KEY PRINCIPLES

Key principles regarding documentation indicate that documentation of the current status of the patient is needed and includes assessment, care plan updates, implementation, and evaluation of care provided, and that documentation is a critical task that nurses perform to protect the patient.

The following is a case study in which documentation played a role in the practice breakdown of nursing care. The story is encapsulated for the reader with a sample of the actual documentation provided by the nurses involved. The reader is encouraged to question whether the documentation truly reflects the story presented.

HISTORICAL CASE STUDY #1: Late and Later Documentation

PRACTICE BREAKDOWN IN DOCUMENTATION

Ms. Amy Jones was a 55-year-old woman being treated for depression at a mental health facility. She was alert, oriented, ambulating without difficulty, and interacting appropriately with staff. The patient’s family was scheduled for a meeting with her treatment team in the afternoon. During the day Ms. Jones met with her psychiatrist, Dr. Ian Smith, in Ms. Jones’s room. When her roommate came in, Dr. Smith suggested that they complete their session in his office, and Ms. Jones accompanied him to that space. On the way she complained that she felt weak but could make it. During the session she reported that she had a headache, which Dr. Smith attributed to anxiety. He went to look for a nurse to provide medication for Ms. Jones. On his return with Ms. Mary Sullivan, a registered nurse, Ms. Jones was on the floor on her knees vomiting. A physician working across the hall came and assisted Dr. Smith and Nurse Sullivan with Ms. Jones, who was now quite somnolent, into a wheelchair. Dr. Allen, the primary care physician, ordered that Ms. Jones be given Phenergan IM for the vomiting and that the nursing staff monitor her bowel sounds. Dr. Allen reported that she was not informed of Ms. Jones’ complaints of headache or loss of bowel control. Dr. Allen thought that she was dealing with gastrointestinal symptoms so she had the nurses check for bowel sounds and softness of the patient’s belly. She reports that she received a second callback and was told bowel sounds were normal, the patient’s stomach was soft, and the patient was resting comfortably. Ms. Jones was bathed and returned to her bed. She took the prescribed Phenergan after which she vomited several more times during that shift. She was incontinent of stool once. No one considered conducting neurologic checks because the staff thought Ms. Jones was suffering from a virus.

When Ms. Jones’s family members arrived, the nurses advised them that their mother was sick and was sleeping, and would not be able to attend the meeting. The family members could not arouse the patient. The staff said that Ms. Jones had been administered Phenergan for vomiting and would be awake by evening. Family members returned that evening and found the patient still unresponsive with vomit in her mouth. The family checked Ms. Jones’ pupils and found them unequal. The family reported to the registered nurse at the desk, and another nurse checked Ms. Jones’ vital signs and reported them to be normal. The family telephoned Ms. Jones’ primary care physician, Dr. Allen, and the nurse gave him a report. Soon after this call, an ambulance transported Ms. Jones to the hospital for evaluation. Ms. Jones subsequently died at the hospital.

Ms. Jones’ daughter stated that the registered nurse did not assess her mother; on arrival in the unit, the EMT assessed Ms. Jones. Ms. Jones’ daughter did not believe that her mother had been adequately monitored from noon to 6:30 PM. She also complained that the nurses were laughing at the family’s concerns about the condition in which they found their mother.

Ms. Cherie Hoffman, a registered nurse, had been employed at the facility for 25 years. She began her career as a nursing assistant, a title she held for 7 years. She then served as a licensed practical nurse for 10 years and then as a registered nurse for the past 6 years. She was familiar with all of the policies and procedures of the facility. On the day of the event Ms. Hoffman was working as the charge nurse; she noted that it was a particularly busy day. She returned from lunch and was informed by Nurse Sullivan that Ms. Jones was ill and had vomited. She was bathed, and the staff had documented her vital signs, completed the Glucoscan, and medicated Ms. Jones with Phenergan per Dr. Allen’s order. The family was not notified of a change in Ms. Jones’ condition because they were expected for a family conference at 3 PM, and Nurse Sullivan hoped that Ms. Jones would feel better by then and could participate in the conference. Nurse Hoffman assisted Nurse Sullivan in monitoring Ms. Jones throughout the rest of the shift. Nurse Hoffman had understood that Ms. Jones had not been sleeping well and thought it would be good to let her sleep. Nurse Hoffman thought Nurse Sullivan had last assessed Ms. Jones at 7 PM.

Nurse Hoffman states she was never informed that Ms. Jones had collapsed prior to vomiting or that she had a headache, or that Ms. Jones was somnolent after the episode. She reported that Ms. Jones had a history of headaches, nausea, and dizziness, all of which had been attributed to medications.

Nurse Sullivan recalls reporting everything to Nurse Hoffman. Nurse Sullivan said she had checked bowel sounds as directed. Ms. Jones was incontinent of stool at 2 PM. and was bathed and repositioned. Around 6 PM. Nurse Sullivan straightened Ms. Jones in bed and said that Ms. Jones looked comfortable. Nurse Sullivan said that she did not feel anxious about the patient, as she thought Ms. Jones was sleeping. Ms. Jones was not on 15-minute checks, but Nurse Sullivan recalled checking on Ms. Jones frequently throughout the shift to assess for vomiting.

Dr. Smith stated that, in retrospect, he should have personally talked to Dr. Allen about Ms. Jones’s condition and communicated to Nurse Sullivan that Ms. Jones had complained about a headache prior to the episode.

PATIENT MEDICAL RECORD: PROGRESS NOTES (ORIGINAL ENTRY AT 7 PM)

O/B client showered and met with Dr. While out with physician, client had episode of vomiting small amounts. Over a period of 30 minutes, client was medicated with Phenergan. Client was later incontinent of a moderate amount of stool. Assisted with activities of daily living (ADLs). Notified Dr. of situation. No further change in Dr.’s orders. Continues to be unresponsive. Physically ill today. Keep MD informed of changes.

Registered Nurse Sullivan

ADDENDUM TO PROGRESS NOTES, DATED TWO DAYS LATER (MEDICAL RECORD ENTRY)

Received a call to assists client in Dr.’s office; client lying on floor, diaphoretic, reported to have felt weak, nauseated, dizzy. Client started to vomit. Assisted and supported client while she vomited 3 times. Two assisted to wheelchair then back to bed—minimal efforts given by patient with transfer. VS, 12:20 97.2 64 16 134/72 (patient lying down). Reported to charge nurse, client changed and washed. Lung sounds assessed, clear all lobes. Phenergan given at 12:20, blood sugar check at 12:30. Rails up, client on right side. 13:00 noticed to have vomited again. Charge nurse notified, vomitus clear yellow with odor. Charge nurse assisted with cleaning patient. Bowel sounds assessed, low gurgling in 4 abdominal quadrants, info given to charge nurse. 14:00 checks. Client noted to be incontinent of stools. Bathed and repositioned. Pulse 60 reg. & even, respirations unlabored, blood sugar done at 16:20. Client repositioned. During checks from 1800-1900 patient’s head had moved, repositioned. Pulse rechecked 56 reg. & even, all clothing washed and hung to dry. A medical change with nausea and tiredness. Charge nurse and MD notified of all information.

Registered Nurse Sullivan

NURSING NOTES (ADDENDUM TO ORIGINAL ENTRY THREE DAYS LATER) (MEDICAL RECORD ENTRY)

I returned from lunch. Another nurse on staff reported to me that Ms. Jones had an episode of vomiting and had to be assisted to bed, to be medicated. After about 15 min, I went into patient’s room. She appeared to be sleeping. I called Dr.’s office and gave the information to some person. Later Dr. returned call and I explained that the patient had vomited several times. I also told Dr. that the patient appeared unresponsive but also informed her that she had been medicated. I gave her a complete set of vital signs and blood sugar. Dr. expressed concern re a possible abdominal problem and asked me to be sure I checked for bowel sounds. I called Dr. a second time to report the situation and told her that bowel sounds were present and that the patient had defecated. Stool was soft, formed, no further vomiting, and the patient continued to be unresponsive; breathing appeared normal (later call received from Dr.’s office regarding condition). I repeated the previous information. Patient was checked q 15 min all day with staff checking and carefully paying attention to be sure that the patient had not vomited any further. She was turned and appeared comfortable. When the patient’s daughter came in to visit, I informed her of her mother’s vomiting and explained that she had been medicated and was sleeping at that time approx 1500. Family returned at approx 1900 and became quite upset and insisted a Dr. be called. The physician on call at that time ordered the patient to be transferred to ER for medical evaluation. This was done at 1930.

Registered Nurse Hoffman

FACILITY ACTION

Nurse Hoffman was placed on 3-month performance probation. This probation was extended for further observation of assessment skills. Subsequently it was determined that competency in this area was still a problem, and her employment was terminated. Nurse Sullivan was allowed to resign in lieu of termination (termination would have been a result of ongoing performance problems related to nursing assessment and documentation).

NURSING BOARD/COMMISSION ACTION

Registered Nurse Hoffman and Registered Nurse Sullivan voluntarily allowed permanent revocation of their registered nurse licenses without admission of violation and without admission to any alleged facts.

ANALYSIS OF CASE STUDY #1

· 1 This case departs from nursing standards specifically as there were (a) failures to accurately assess and document the patient’s condition and (b) failures to notify/accurately report change in the patient’s condition to the physician. In particular, the patient’s decreased level of alertness was not accurately conveyed with relevant questions and interpretations.

· a An acceptable level of performance. The nurse instituted physician orders and monitored the patient during her change in condition. The nurse documented the medications administered, patient vomiting, and bowel status.

· b An unacceptable level of performance. The level of medical review and examination was inadequate on the part of the psychiatrist, Dr. Smith, and the patient’s primary care physician, Dr. Allen. Neither doctor performed even a minimum level of physical examination, evaluation of neurologic status, or followed through on the patient’s “overreaction” to Phenergan.

· c An unacceptable level of performance. The nurses’ ongoing assessment and communication of the patient’s deteriorating condition was inadequate. The nurses were not adequately attentive to the puzzling situation of the patient remaining somnolent for so long, nor did the nurses conduct a neurologic check on the patient. The nurses did not obtain complete information from the physician regarding precipitating events prior to the acute illness episode. Poor communication between the physician and the nurses and failure to document and communicate these concerns to the primary physician resulted in a misdiagnosis and inappropriate treatment of the patient. Specifically, the failure was that the staff did not completely document and communicate the patient’s condition, which included (1) incontinence, (2) decreased level of consciousness, (3) no neurologic checks, (4) finding the patient on the floor, and (5) diaphoretic state. There was a failure to document the ongoing assessments, and the monitoring and evaluation of interventions implemented. Finally, late entries of documentations of significant interventions and assessments meant that these assessments were not available to other members of the team during the incident.

· 2 System issues focused on (a) leadership, (b) workforce, (c) work processes, and (d) organizational culture.

· a Leadership

· 1) Lack of process regarding communication between psychiatrist and primary care physician resulting in poor coordination of care.

· 2) Lack of policy on complete assessments and documentation of patients following a change in patient’s physical and mental condition.

· b Experienced workforce. Leadership was not adequately monitoring workforce skills and competency. A review of the incident and monitoring actions found that knowledge and performance deficits were noted for both nurses resulting in their termination and resignation.

· c Work processes. The investigation found that a process was not in place to ensure coverage during lunch, and there was a breakdown in formal communication among staff. No one nurse was identified as “assigned” to assume total responsibility for the patient.

· d Organizational culture. The investigation results indicated a lack of clear, concise communication and a multidisciplinary approach with poor coordination of care.

· 3 Individual Nurse Issues. Nurse Hoffman was responsible for the entire unit. She received a report on a change in the patient’s condition. She did not get a full and complete report from Nurse Sullivan and failed to collaborate with the physician. She called the primary physician and relayed the incomplete information to the physician. It would have been preferable for Nurse Sullivan to call the physician because she had made a direct assessment of the patient and was best able to communicate the patient’s condition and answer any questions. Nurse Hoffman stated that she monitored the patient during the shift. She failed to document the monitoring or describe what her monitoring entailed.

· 4 Practice Responsibilities. The practice responsibilities expected in this situation included (a) an assessment of the patient, (b) documentation of the assessment, (c) a plan to address the patient’s needs that included coordination with the multidisciplinary team, (d) steps to implement the physician’s orders and measures to ensure ongoing nursing assessments of the patient’s responses to the medication given, (e) an evaluation of the patient’s response to care, documented along with a report of any changes or deviations from expected outcomes; and (f) measures to initiate the process over again. In this situation, the patient needed to be sent to the emergency room earlier for physical assessment or examined initially by the primary care physician, preferably in the psychiatrist’s office, and at the time the patient returned to the unit incapacitated.

Clearly the entire staff was not thinking about the possibilities that the patient could have a serious condition other than her psychological condition and the hypothesized “virus,” abdominal problems, or high blood sugar levels. Psychiatric facilities have a “set” to think about psychiatric problems rather than medical-surgical problems. Both physicians and the nurses failed to conduct adequate assessments given the level of Ms. Jones signs and symptoms. Curiosity and vigilance were lacking with regard to Ms. Jones puzzling deterioration, and adequate documentation of signs and symptoms and the continued somnolence and deterioration of the patient were not adequately reported or documented. This tragic case is a signal event that must be highlighted in the psychiatric facility in order to improve nursing and physician assessments of patients for medical conditions and to avoid a repeated dangerous selective focus on psychiatric problems only.

ADDITIONAL EXAMPLES

Following are other examples of documentation that do not conform to nursing standards of documentation:

Nurse Daniels reported to work for her evening shift. She was told by the day shift that there was an admission expected that evening. She was informed that one of the other nurses had called in sick. She considered calling the house supervisor and requesting more staff but decided against it. She assessed the situation and tried to prioritize her responsibilities for the shift.

Nurse Daniels told herself that if she hurried and cut a few corners she would be able to handle the workload. She started her evening administration of medications. She decided it would save time if she signed all of the Medication Administration Records (MARs) first, then administered the medications to patients. She was familiar with all of the patients and the medications they received in the evening so this made sense to her. She went through the MARs and signed all of the evening medications. She was about halfway through administering medications to patients when she became nauseated and diaphoretic. She started vomiting. Another nurse took her temperature and called her husband to come and drive her home.

The house supervisor was informed of the situation and assigned Nurse Martin, a float nurse, to cover for Nurse Daniels. Nurse Martin reviewed the MARs and determined the evening medications had all been passed out before Nurse Daniels became ill and had to leave. Later in the shift, some of the patients reported they had not received their evening medications. Nurse Martin was in an impossible situation of trying to determine who had and who had not received their medications.

Although well intended, Nurse Daniels’ actions resulted in several medication omissions including blood pressure medications, antibiotics, and blood thinners. What seemed to be a harmless shortcut turned out to be dangerous. Hospitals are complex environments with many interruptions. Documentation is a major line of defense for patient safety. Omitting documentation or documenting prior to actual interventions puts patients in jeopardy.

In another situation, Nurse Cross was assigned to perform blood sugar Accu-Check monitoring for the shift on her unit. After she completed all of the Accu-Check monitoring, she referred to her notes and charted the values in her patients’ records. She realized she must have written the results for the patient, Ms. Nancy Bruno, on a separate piece of paper that was not in her uniform pocket but was rather on another note that she had left in the medication room. She felt fairly certain that she remembered it to be 280. This violates a patient safety precaution against relying on memory for laboratory values, dosages, or even normal ranges, etc. The nurse was in a hurry and recorded the 280, intending to find her other note and double-check the number. Meanwhile she became busy and forgot to check for the actual correct number. Ms. Bruno was a patient on a sliding scale for her insulin. Nurse Brown was passing out medications during that shift. She noted the 280 and administered insulin accordingly. Ms. Bruno’s Accu-Check was actually 180, and consequently too much insulin was given for the blood sugar level. Ms. Bruno had a reaction and required administration of glucagon and close monitoring.

Again, although Nurse Cross had good intentions, she cut corners and did not follow nursing standards for medication administration. As a result, Ms. Bruno was put at serious risk and suffered an unnecessary adverse reaction.

SUMMARY

Documentation is a contested area of nursing practice. Nurses complain that they spend too much time on documentation and that their work demands often preclude timely charting.  Keenan et al. (2008)  identified the following key research questions for documentation:

· 1How does variability in documentation impact patient outcomes?

· 2What are the key components of an effective documentation process that is patient centered and improves the transfer of information among clinicians and across settings of care?

· 3What aspects of documentation are shared among an interdisciplinary team, and what contributions to the patient record can each team member effectively provide?

· 4Should documentation vary across settings of care ( Keenan et al., 2008 )?

The TERCAP® tool can add address post hoc patterns of documentation that are associated with poor patient outcomes. False documentation to cover up any kind of error is a serious breach of nursing professional standards and is reportable to the state board of nursing. Likewise “late charting,” especially several days after the event, is highly problematic and prone to error, and hindsight filling in information that was not discerned or known at the time of the unfolding of an event is a serious breach of professional standards.  Keenan et al. (2008)  concluded that we have a long way to go in improving the design and safety and quality improvement of nursing documentation and planning of patient care. After their extensive literature review, they drew the following conclusions:

· The evidence reviewed in this chapter suggests that formal recordkeeping practices (documentation into the medical record) are failing to fulfill their primary purpose, of supporting information flow that ensures the continuity, quality, and safety of care. Moreover, disproportionate attention to secondary purposes (e.g., accreditation and legal standards) has produced a medical record that is document centered rather than patient focused. Cumbersome and variable formats, useless content, poor accessibility, and shadow records are all evidence of the extraordinary failure of the medical record. Given the exorbitant cost of the record and urgent need for tools that facilitate the flow of patient-centric information within and across systems, it is imperative to develop broad-based solutions.

The TERCAP database from the state board of nursing will potentially provide a useful source of data on the impact of nursing documentation on serious reportable nursing errors that come to the state board of nursing.

References

G.M. Keenan, E. Yakel, D. Tschannen, M. Mandeville: Documentation and the nurse care planning process. In R. Hughes (Ed.): Patient safety and quality: A handbook for nurses. 2008, Agency for Healthcare Policy and Research, Rockville, MD, 1–33, Available online at  www.ahrq.gov/qual/nurseshdbk/ , Accessed 10-30-2008.

L. Korst, A. Eusebio-Angeja, T. Chamorrow, C. Aydin, K. Gregory: Nursing documentation time during implementation of an electronic medical record. Journal of the American Medical Association. 33(1), 2003, 24–30.

S. Meiner: In Nursing documentation: Legal focus across practice settings. 1999, Sage, Thousand Oaks, CA.

M. Pabst, J. Scherubel, A. Minnick: The impact of computerized documentation on nurses’ use of time. Computers in Nursing. 14(1), 1996, 25–30.

In A. Page (Ed.): Keeping patients safe: Transforming the work environment of nurses. Committee on the Work Environment for Nurses and Patient Safety, Institute of Medicine 2004, The National Academies Press, Washington, DC:.

G. von Krogh, C. Dale, D. Naden: A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. Journal of Nursing Scholarship. 37(3), 2005, 275–281.