Documentation: Impact on Quality of Care

Nurses document on patient records many times during any work day. We may even complain that we spend more time charting than we do with our patients. Although that may be true, we should remember that patient care isn’t just “hands-on”. Documentation in nursing is also an integral part of providing quality and safe care to our patients.

We learn in nursing school that a patient record is a legal document. We also learn that “if it isn’t charted, it isn’t done.” We should consider these facts in practical terms and not just as something our instructors repeated numerous times.

Standard of care includes the principle that any of your coworkers should be able to pick up a chart and understand the status of that patient’s condition and care. Quality care is a team effort. The team must work together to ensure that each patient’s individual needs are clearly communicated to each other.  

 

Another issue with regards to documentation is financial reimbursement. Third party payers evaluate the documentation in a patient record to determine whether payment is appropriate.

 

Documentation and the medical necessity of treatment are closely scrutinized and at times payment may be denied. We cannot forget that health care is a business. Funding for facilities can determine the types of care that can be offered, the numbers of staff employed, etc., thereby also potentially impacting quality of care.

 

Potential litigation is an issue that we would probably rather not consider, however a patient record may form the basis for the filing of a lawsuit against medical malpractice. Typically, in litigation, the record is reviewed by an “expert” working for the plaintiff’s attorney, and he or she will render an opinion on the quality and appropriateness of the care provided.

 

A nurse is expected to act as a reasonably prudent nurse with the same level of training and experience would act in a similar situation. Be assured that the medical record will likely be scrutinized line by line and in part to ascertain whether this legal standard is met.

 

An accurate medical record is the nurse’s best defense. Once litigation begins, it may take several years until resolution. If you are subpoenaed for deposition or as a witness at trial, it is probable that you will not remember the specific patient, exactly what you did and when, etc. Even if a treatment was performed as ordered, if the record doesn’t reflect this, the chances that the plaintiff may prevail could increase.

 

Another important legal issue involves potential disciplinary action by the Board of Nursing against your license, as the result of inadequate or falsified documentation. Each Board of Nursing has its own set of Laws and Rules, however, all exist only to protect the public from nurses who have demonstrated that they are unable to practice in a competent manner. If a complaint is filed against your license, even the possible loss or restriction of practice is a sobering experience.