Developments in Indiana Law

Strategies for Minimizing Claims through Effective Charting

By: Nathan A. Leach

In my practice defending nursing homes and other healthcare providers I have learned that charting serves multiple purposes. However, a few of the primary purposes are to: establish a resident's medical conditions and care needs; document the care provided; document the resident's results and progress; and communicate with all members of the resident's healthcare team and ensure continuity of care.

In negligence claims against nursing homes the chart is the starting point for any and all claims. First, the potential claimant's attorney analyzes the chart for potential breaches in the standard of care and injuries to the resident. Typically the claimant's attorney initially focuses on: sloppy/incomplete notes, significant gaps in the chart, delays in initiating treatment, improper assessments, altered entries, and suspect late entries. I always stress to my clients that quality documentation may deter an attorney from taking a case. As such, strong nursing documentation is the first line of defense.

Similarly, the nursing home defense attorney looks for quality notes that document the resident's care plan and demonstrate that quality care was provided. Often the quality of the notes will impact whether or not the facility will consider an early settlement. If it's not documented, it's more difficult to prove that particular part of care at issue was rendered. Moreover, the lack of documentation makes it more difficult for a nurse to maintain his or her credibility in front of a jury. I commonly tell nurses that they should always strive to be proud of his or her documentation and able to defend if ever questioned.

In my practice, I have also learned several keys to quality charting. For example, charting must be accurate. Although some problems with accuracy have been eliminated through the use of electronic medical records, the nurse must still be sure that his or her notes are accurate. The notes should objectively and comprehensively state the care that was rendered to the resident and should specifically identify the time that the care was provided. The nurse should sign each and every note. If still charting by hand, the nurse must make sure the notes are neat and legible. Illegible handwriting looks unprofessional and could potentially cause confusion to other care providers relying upon the documentation.

Furthermore, the charting must be complete. The nurse should chart all care and treatment provided and the resident's response so as to provide a complete picture. If the resident has a change in condition, the nurse should thoroughly document the change and document the notification of the resident's physician and family member. I commonly advise nurses to always document a resident's non-compliance, family member statements (positive and negative), invitations to attend care plan meetings, and the resident's conditions and treatments at the time of the resident's admission (particularly documenting the resident's skin condition and orders received). However, it is equally important for the nurse to chart information concerning the resident at the time of discharge. Likewise, it is always important to document communication concerning the resident's expectations to the resident's family.

In this regard, due to the characteristics of the nursing home population, poor outcomes are common. However, poor outcomes are not always anticipated by the resident's family. As such, the nurse should explain and thoroughly document the resident's expected outcome in advance. Likewise, the nurse should document that the expectations were discussed with the resident's family and that the expectations were understood. If there are changes in the resident's conditions, the nurse must document the change and the timely notification of the resident's physician.

Nursing notes should also be objective and timely. The nurse should document what is observed, not his or her opinions and/or assumptions. The resident's exact words should be quoted when possible, not the nurse's interpretations of what was said. The nurse should chart promptly so as to be able to provide specific details and ensure accuracy. It is also worth mentioning that the nurse should never chart in advance. Although this may occur in effort to be more efficient with the nurse's valuable time, it has the potential to lead to inaccurate documentation. Lastly, nursing notes should be chronological. The timing of care in most cases is very important. The nurse should chart in chronological order as this is the most logical way to explain the care provided to the resident. The nurse's entry should always be dated and the exact time entered. In this regard, patient improvement or deterioration is easier to spot when events are charted in the order they occur. If an error has been made, the nurse should correct in compliance with the facility's policy.

If nurse's follow the above advice and procedures, we will be in a much better position to defend potential claims.

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