There are different methods of charting. While one institution may consolidate all of the progress notes on one interdisciplinary progress sheet, another institution may have several progress notes (i.e.: one for nurses, another for physicians and yet additional forms or progress notes for other ancillary health care providers) .
Practices vary widely from one institution to another. While many hospitals are switching over to a computerized charting system where everything is legibly typed and easy to read; other facilities still use the old fashioned handwriting techniques, which can often be difficult to decipher.
This continuing education program will review the basic documents that are found in a patientís medical record. It is not all inclusive. Some facilities will have additional forms and others may not utilize all forms that are listed here, but overall you will find that most health care facilities will employ the following documents:
1. Admission Demographic Sheet
2. Consent for Treatment
3. Triage Assessment
4. Nursing Assessment
5. Nursing Notes
6. Flow Records
7. Physicianís Assessment
8. Physicianís Orders
9. Laboratory Reports
10. Radiology Reports
11. Electrocardiogram Reports
12. Respiratory Therapy Records
13. Discharge Instructions
14. Discharge Summary
These fourteen elements of the medical record are fairly standard and can be found in almost every patient's record that is admitted through the emergency department.
Admission Demographic Sheet
The first document that we will look at is the Admission Demographic Sheet. It contains the patientís Chief Complaint. This document represents the very first contact that an individual has had with a health care provider or representative of a particular health care institution.
The chief complaint, can be what the patient actually states. For example, a patient may come in and say that he has chest pain so the Admission Demographic Sheet will say chest pain. Perhaps later on in the course of evaluation and treatment the chest pain turns out to be related to a non-cardiac event; simply that someone punched him in the chest and his ribs hurt. The complaint or problem listed on the Admission Demographic Sheet is usually the very least accurate and may not always represent the patientís actual condition.
You may also find that there are multiple drafts of the Admission Demographic Sheet. The reason for this is that patientís often will present to the emergency department and not have all of the information that they need. Some of the information initially provided may not be accurate and may need to be updated. The Admission Demographic Sheet contains insurance information, which could be valuable to an attorney when dealing with HMOs and referrals.
Allergies are sometimes found on the Admission Demographic Sheet along with next of kin information and information about their personal physician. This form is valuable in that it sometimes provides the very initial impression that the hospital staff receives regarding the patient contact. It is important to note that more often than not this information is gathered by a non-medical professional, that is to say a unit clerk, secretary or admission clerk.
Information about Advanced Directives are sometimes indicated on the Admission Demographic Sheet simply as a yes or no (whether the patient has initiated an advanced directive or not). Certain institutions may have a separate form for this purpose.
The next step in an emergency hospital admission is to see the triage nurse. In some institutions this process will generate a separate document. In other places the documentation will be included on the Nurseís Assessment Sheet or at the top of the Physicianís Assessment.
Triage, as you may know, simply means to sort out. Today this is still done to prioritize care. It was initially and still is utilized for mass casualties where different color tags are used to designate the severity of the patientís injuries.
A patient is literally tagged. On that tag is a color which indicates a treatment priority level. A white tag is placed on the walking wounded. These people have minor injuries and perhaps require first aid. A physicianís care is not needed. Minor injuries such as cuts, scrapes and minor burns, that can be taken care of at home or with basic first aid are triaged white.
A patient designated as green is also a walking wounded. These patients can wait several hours or perhaps even days to receive a doctorís care. This person could go home and come back at a time when the health care facility is less congested and better able to handle the traffic.
A yellow classification signifies overall stability. It requires monitoring by a trained professional and frequent re-triaging (that means re-evaluating). Triage is not something that's intended to be a one-time event, but an ongoing process. A yellow classification indicates a need for immediate care under normal circumstances. Note that this system is used for mass casualty thus, these are not normal circumstances. The patient would be monitored by a trained professional and re-triaged. These patients are considered to be stable at the time and even though normally would be seen immediately they could wait for an undetermined amount of time depending on their specific complaint and assessment findings.
A red triage card is used to indicate the need for immediate life-saving interventions. This person can not wait to be treated later. Often these patients need immediate surgery or other medical procedure.
Finally the black tags are used for those who are so severely injured that they would more than likely die in spite of heroic intervention. This means that someone in cardiopulmonary arrest would get a black tag. Time would not be wasted trying to resuscitate these people because there is a good chance they would probably die anyways.
Someone with multiple traumatic injuries is triaged as black if they are not expected to survive. Heroic interventions are not attempted because time and resources could be better spent trying to save someone with a better chance of survival.
Today, as the triage system has evolved into the health care setting in the busy emergency departments we obviously donít triage anyone black and just leave them for dead. Under ordinary conditions they are triaged red (emergent or critical depending on the health care facility).
We will now review the differences in triage systems that are implemented throughout the State. The first one is a 4-level triage, which covers emergent, urgent, non-urgent and clinic severities. These are mostly self-explanatory with emergent classification for the most critical and clinic designation for the person who really doesnít need to be seen in the emergency department, but could be better served in an outpatient clinic. This system corresponds well with red/yellow/green/white.
Some facilities utilize a 3-level triage which consists of emergent, urgent and non-urgent. Again, these are self-explanatory. The only difference here is that green and white are placed in the same category.
The 5-category Emergency Severity Index triage assessment tool is utilized in most facilities today and has become the standard triage assessment format.
Level One is the most severe (red). This individual would have an unstable condition and without immediate intervention this person would die. A physician is required at the bedside immediately to intervene. Many intensive care level patients would qualify for Level One. They are seen immediately because timeliness will affect their morbidity and mortality. These patients account for only about 1% to 3% of all of emergency department visits throughout the country. They represent the true life and death emergencies.
Level Two patients are also quite sick (yellow). They require a nurse to initiate patient care as guided by protocols and standing orders, but not necessarily a physician to be present at the bedside for immediate intervention. These people are critical and they require a physician's evaluation and intervention after the nurse has initiated protocols. These patients should never be sent to the waiting room. They are too sick and need immediate care.
The only difference between Level Two and Level One is that Level One requires a physicianís immediate expertise and intervention. Level Two requires a nurseís immediate intervention per protocol and certain standing orders. The physician should follow closely behind. These account for about 20% to 30% of emergency department visits throughout the country.
Level Three patients account for about 30% to 40% of all ER patients. Levels Three, Four and Five are all determined by the anticipated number of resources that the patient is likely to require. Resources are defined as health care interventions.
If the patient will require laboratory work, that would counted as one resource. Some common additional resources are: cardiograms, intravenous medications, intramuscular medications, aerosol medication, intravenous fluids, x-rays, any kind of specialty consultation, and any kind of specialized radiology beyond a simple x-ray (i.e.: CT scan or MRI). Simple procedures performed by a physician or nurse (i.e.: sutures, insertion of a nasal gastric tube or Foley catheter) are also considered resources. Complex procedures like conscious sedation or chest tube insertion count as two resources.
When nurses triage a patient, they have to think about how many resources the person is going to need and then make a determination as to the ESI level. Level Three patients require two or more resources to be properly evaluated. Level Four only require a single resource. Level Five patients need no resources. All they require is an examination by a doctor.
It is estimated that ESI Levels Four and Five account for about 20% to 30% of the patients seen in the emergency departments.
Nursing triage may or may not be a part of the Nursing Assessment Sheet. Some facilities use a separate form for triage only.
The Triage Assessment Sheet should include a brief initial complaint as presented by the patient, an assessment, the triage category designated and a disposition. Once the person is triaged, he is either brought back to a treatment room or sent to the waiting area.
ER Nursing Assessment Sheet
When a patient is brought back to the treatment area, an ER Nursing Assessment Sheet is completed, which is different from the triage assessment. This should reflect any changes in findings from the triage nurse's assessment. Some facilities have computer generated Nursing Assessment Sheets and Physician Assessment Sheets that are driven by a preliminary diagnosis or chief complaint. Other hospitals use standard generic assessment sheets that are used for every patient. The initial complaint, initial assessment, interventions and treatments are usually part of the Nursing Assessment Sheet. This information can be used to compare the nursesí findings to the physicianís. It is also useful to compare with the initial triage nurseís assessment.
ER Nurseís Notes
The ER Nurseís Notes may or may not be separate from the ER Nursing Assessment Sheet. On the floor, the Nurseís Notes are usually separate from the Nursing Assessment.. Some hospitals use narrative entries and some utilize a check sheet format. Nurseís Notes contain nursing procedures, response to procedures and medications. They are focused on reassessments and treatments. This information is used by the LNC to correlate assessment findings with interventions and the physician's orders.
ER Physicianís Assessment Sheet
The ER Physicianís Assessment Sheet can be diagnosis driven or generic. It contains the history and physical, review of systems, tests ordered and results, impressions and diagnosis, treatments, referrals, consultations, and finally the patientís disposition and any applicable discharge instructions. The LNC examines this information in conjunction with the nurseís documentation and other relevant records for continuity of care and identification of applicable standards.
ER Physicianís Orders
The next item is the ER Physicianís Orders. This is where the doctor will actually write out tests, treatments, procedures, discharge instructions, monitoring parameters and anything else that he would like done for the patient. Occasionally you will find Physicianís Orders that are entered on a computer. More often than not, it will be handwritten and there can be some challenges in deciphering handwriting. One of the things to look for on a Physician's Order Sheet is whether or not the orders were ever noted. To note an order means that someone has taken ďnoteĒ of the order. Simply stated it means that someone has seen the order and started the process that is required to execute that order.
If an order is not noted, then it is possible that it may have never been seen by a nurse or other health care provider. The typical procedure in many hospitals is for the physician to write the order and flag it somehow. That could mean that the chart is tagged or that it is placed on a certain rack or box, which alerts the staff that a new order has been written by the doctor. If there is a unit secretary on duty, usually the secretary will look at those orders and begin the process. Often, all that is needed is for the order to be entered into a computer or when the patient is on the floor it may be written on a card -X. Laboratory orders and monitoring parameters are a good example of this. The unit secretary then brings the orders to the attention of the nurse. When the nurse notes these orders the nurse is signing that the orders have actually been initiated. It is important to carefully review orders and ascertain whether they were carried out. The actual execution of any given order may be found in various parts of the medical record. This is sometimes difficult to verify because the same test, procedure or medication can have many different names. A basic metabolic profile may be ordered by the physician and reported by the laboratory as a Chem-8 or basic chemistry.
The ER Flow Record
There are many variations of ER Flow Records. Some facilities will employ one Flow Record to include medications, intake, output, vital signs, procedures and even Glucometer readings and wound care, but many facilities use separate Flow Records for each one of these tasks, especially outside of the ER setting. If a particular intervention is not documented in the Nursesí Notes or Assessment Sheets it might be on one of the Flow Records.
ER Parenteral Therapy Record
The ER Intravenous or Parenteral Therapy Record may be a separate document which is used by the nursing staff to document intravenous access, intravenous site assessments, dressing changes, intravenous medications, tubing changes and other intravenous therapy related items. IV therapy documentation may also be incorporated into the Intake Sheet. In some institutions it will be part of an I&O (intake and output) Sheet.
Intake and Output Sheet
As the name suggests, is a record of how much volume the patient receives and how much volume the patient puts out. Interpreting these numbers is important when monitoring patients who are sensitive to fluid overload or dehydration. Sometimes the I&O record is part of the more comprehensive Nursing Flow Sheet or may be incorporated into a Vital Signs Flow Record. Other institutions will use a separate form for vital signs.
Electrocardiogram Monitoring Strips
These recorded tracings may be documented on a progress note or on a separate sheet that is designed for mounting strips. Sometimes the monitoring strips are placed in the Respiratory Therapy Record and sometimes they are part of the Integrated Progress Notes. Interpreting monitor strips correctly is an essential component of proper cardiac assessment. Certain cardiac rhythms are associated with specific protocols and standards of care.
The MAR or Medication Administration Record, as the name implies, is simply a record of the medications that have been given to the patient. Most emergency departments do not have a separate MAR; instead they incorporate this information into the Nurseís Notes or Flow Sheet. After admission to the floor, hospitals generally develop a separate MAR sheet for each day consisting of a 24-hour period. Nursing homes and other long-term care facilities, where medication changes are infrequent, will utilize an MAR flow sheet that may cover an entire monthís span to document their medications.
The procedure for documenting the administration of a medication varies from institution to institution. Generally, the administering nurse's initials are placed next to the name of the medication with the time and dosage that were given.
MARs in a general hospital setting are frequently changed because medication dosages and frequencies are often subject to change from day to day depending on the patientís condition. You will find that almost all medical records will include medications on the MAR, which are typewritten by the pharmacy and medications that are written in by hand. The reason for this is that the pharmacy updates the Medication Administration Records at certain intervals. If a medication is ordered as a one-time dose, STAT dose, is ordered at a time when the pharmacist is not available or a time in-between those intervals when the MAR is updated, then the nurse will write the medication in by hand. Many facilities have a separate Medication Administration Record for PRN medications, which are given as needed or one-time only.
Sometimes a medication may have been administered and not documented on the MAR. The documentation could exist somewhere else in the patientís medical record. The nurse may have charted a medication in the Progress Notes, Flow Sheet, Vital Signs Record or in some cases a Pain Assessment Sheet. Medications can also be charted right on the Physician's Order Sheet. This is sometimes seen in the emergency department especially, if it is a stat or one-time medication.
Unfortunately, each medicine may have multiple brand names. Although the physician ordered potassium chloride; the nurse could document K-Dur instead. This makes verification of medication administration somewhat of a challenge. Fortunately, various drug handbooks and the internet have greatly simplified the research process.
Pain Assessment Sheet
A Pain Assessment Sheet could exist independently of other documentation or there could be a pain assessment area on another assessment sheet. Sometimes the pain assessment is incorporated into a flow sheet, which is used for other purposes.
ER Code Blue Record
A Code Blue Record may or may not be initiated in a code blue situation. They are, more often than not, used in the emergency hospital setting and on the floors. A Code Blue Sheet is usually started when CPR is initiated. It documents emergency interventions including intubation, defibrillation, drugs and other procedures for the duration of the code blue until the patient either expires or is stabilized. It is important to note that not all interventions and actions are documented on the Code Blue Sheet. Because a code blue situation often involves a progressive deterioration of the patientís condition, many of the events leading up to the code blue will be documented elsewhere in the medical record. These events may be recorded in the Progress Notes, Integrated Progress Notes, Physicianís Orders, Physicianís Progress Notes and Nursing Notes. The Code Blue Sheet bears important information which helps the LNC identify specific standards of care and compliance.
ER Trauma Flow Sheet
This Flow Sheet is similar to a Code Blue Sheet and is used for trauma situations in the emergency department. Smaller facilities do not utilize this record however, and simply use the standard emergency department chart. Medical and nursing procedures, medications and other interventions can be found on this document. This document can be very helpful because specific protocols and standards are used in some types of trauma, thus any information recorded can be used to evaluate whether these standards were adhered to.
Conscious Sedation Record
This Record is generated when patients are having a procedure which requires what is known as conscious sedation. This means that the patients remain conscious, thus not fully anesthetized, but are given enough medication so that they are asleep, or in and out of a sleeping pattern during the entire procedure. Often the patients will not have any recollection of the procedure or the events surrounding it. This document will contain the vital signs and other monitoring parameters utilized during the procedure and for a period of time after the procedure is completed, until the patient is fully recovered. Inadequate monitoring during a conscious sedation may result in preventable complications such as aspiration, fall injuries and cardiopulmonary arrest.
Dictated reports are beneficial because of their legibility and specificity. History and Physicals which are done by the admitting physician, Consultation Reports, which are obviously done by consultants, Radiology Reports and other miscellaneous reports completed by allied health care professionals, may all be dictated. Surgical procedures are usually dictated in great detail. Discharge summaries are also commonly dictated.
The turnover time from procedure to dictation varies greatly in practice from physician to physician. Some doctors will dictate immediately after performing a procedure or doing an assessment, while others wait until the next day or a time when it is more convenient.
Physicians will sometimes batch all of their charts and dictate them together at one sitting.
The medical records department screens the chart after the patient is discharged and looks for missing documentation. They will then notify the physician of the documentation deficiency. The doctor will eventually dictate a report, but this may not occur for days or even weeks after the patient has been discharged from the hospital, thus there may be a discrepancy between the date of dictation and the actual procedure. This is especially common during holiday and vacation periods. As physicians are eager to leave town they may also leave behind several unfinished charts.
If a significant time discrepancy exists it may result in certain errors related to memory recall of the events. This can be explored at deposition.
Consultation Reports as mentioned previously are usually dictated, but sometimes the physician will be in the habit or practice of actually handwriting the entry in the Progress Notes of the medical record. As with any handwritten document, penmanship may be difficult to decipher. Some attorneys find it helpful to have illegible documents transcribed/translated by a legal nurse consultant.
Laboratory and other diagnostic reports usually exist in a typewritten form. Rarely a laboratory result or diagnostic test will be reported on a handwritten progress note or handwritten laboratory slip. When this occurs it usually signifies a computer or printer failure.
Certain test results may be referenced in the physicianís History and Physical, in their Consultation Reports and in their Discharge Summaries. Properly interpreted test results can be of great value in establishing applicable standards of care.
These orders are usually written in the emergency department by the emergency department physician. Occasionally when an admitting physician or the consulting physician comes to see the patient in the emergency room they will write the admitting orders themselves. However, most admitting orders are written by the emergency room doctors. These orders are intended to be preliminary, and in most cases to cover the first 24 hours of hospitalization. Afterwards, the admitting physician will have had time to evaluate the patient more thoroughly, perform additional tests, have certain diagnostic results available and determine a more definitive plan of care. These orders help to identify the plan of care and thought process of the physician.
Protocols (standing orders)
There may be protocols in place that have been agreed upon by the medical staff which apply to all patients. These may be a part of, or separate from the Policies & Procedures Manual.
Potassium, magnesium, heparin, integrillin, and nitroglycerine are medications which are often administered per protocol. Many are in the form of an algorhythm which outlines treatment pathways based on specific clinical findings or responses. This avoids the need to call a physician for a specific order during every step of many common treatment modalities.
Protocols are beneficial for avoiding delays and facilitating prompt treatment when indicated. Unfortunately this places an increased burden on the nurse to determine if the protocol is appropriate for the patients unique situation. For this reason most protocols exist as a pre-written set of orders which is stamped with the patientís name and signed by the physician to indicate that he has determined that the protocol in question is appropriate for the patient. The nurse is still responsible to make sure that changes in the patientís condition do not warrant further physician consultation before proceeding with the established protocol.
Because of personal preferences which are based on individual experience and training it is not uncommon for each physicians to have a slightly different protocol for treating the same clinical problem. After all, medicine is not an exact science and has been often likened to an art form.
The appropriateness of executing a protocol must be evaluated like any other course of treatment; case by case.
The immediate pre and post surgical treatment of patients with cardiac bypass (CABG), joint replacements (artherectomy & arthroplasty), blood vessel studies (angiography), blood vessel surgery (angioplasty), brain surgery (craniotomy), gastrointestinal and urinary procedures, and other surgeries are commonly treated with pre-written standing orders/protocols.
Admission History and Physical
The Admission History and Physical is generally performed by the admitting physician when he first comes to see the patient after being admitted through the emergency department. Consultations are very similar in content to the History and Physical, but are mainly utilized to document the findings of the consultant in his specialty area. Most of the documentation will consist of a focused assessment in that specialty. These documents are rich in information and of great value when trying to summarize findings and events.
The Nursing Admission Sheet
This is a form used to record the initial nursing documentation that is done after the patient is admitted to a hospital room. It will include some basic information such as: height, weight, religious preference, nutritional preference, fall risk assessment and a comprehensive assessment of the patientís condition and potential problems. This form is used to help identify information which is used to generate the initial Nursing Care Plan.
Some Nursing Assessment Sheets include a Nursing Care Plan while other institutions choose to make that a separate document.
These notes are very useful because they usually provide a good picture of the patientís daily progress during his hospitalization and any significant events that may have transpired. In many hospitals the Progress Notes are shared by physicians, nurses and allied health care professionals. Some institutions have separate progress notes to be used only by physicians, another one for nurses and even a third for other ancillary personnel.
Physicians utilize the progress note to document their daily assessment of the patient, as well as changes in the plan of care and course of treatment.
Nurses generally utilize this area to document conversations that are taking place with other health care professionals and any other item that does not conveniently fit on any of the other forms which they use.
Some nurses prefer to use the Progress Note over flow sheets. Even though a specific flow sheet may exist for a certain purpose the nurse may chose to document on the Progress Note instead. This can be problematic if you are searching for a certain piece of information which should be on a particular flow sheet, but the nurse has decided to use the Progress Note for documentation. This is a common practice, so when in doubt look for the documentation in the Progress Notes.
Generally speaking, any issues which concerns the Plan of Care and any communication between the doctor and nurse or other health care providers is documented on the Progress Notes.
Daily Nursing Assessment Sheet
In addition to the initial nursing assessment done upon admission to the hospital, a Daily Nursing Assessment Sheet is also utilized in the hospital setting. This is where the nurse documents a complete assessment every shift. It includes a review of systems, documentation of pain control, safety, patient and family teaching, equipment used, treatments that were performed, procedures that were carried out, and medications administered. It is not unusual to find documentation regarding notification of patientís families, notification of physicians, and collaboration with other health care professionals documented within the Daily Nursing Assessment Sheet. It is also possible to find medications documented in this area, which pertain to a certain level of pain, treatment, or procedure. It is important to compare findings on the Daily Nursing Assessment Sheets with those which were documented by the physician.
Nursing Care Plan
The care plan is usually generated on admission and it is updated on a daily basis. It includes nursing diagnoses and nursing interventions, which are separate from physician driven diagnoses and interventions. Simply stated; these are independent nursing actions based on independent nursing diagnoses. In other words something that a nurse can diagnose and care for independently of a physicianís order. An example of a nursing diagnosis is: knowledge deficit of prescribed medications. The independent nursing intervention would be to teach the patient about their medications. This is something that the nurse can do without a doctorís order.
Nursing Flow Sheets
There are a variety of flow sheets; they may include the documentation of intake and output, vital signs, equipment which was used for the patient, cardiac rhythm strips, and interventions. Some facilities have separate flow sheets for all of these. Most of these forms are generated on a daily basis. In some institutions they may cover more than one 24-hour period. Nursing homes and extended care facilities may have as much as a month's worth of documentation in any one of these areas on one piece of paper.
Neuro Check Sheet
This document is used for close and frequent monitoring of neurological status.
It is commonly used in patients with stroke, brain surgery, head injury, drug overdose, and when the patient has an actual or high potential for compromised level of consciousness. Although a neurological assessment may be documented on a progress note or other flow sheet, the advantage of the Neuro Check Sheet is that it is easier to identify trends and acute changes.
Intervention Flow Sheets
Some facilities may utilize a different sheet for each type of intervention. For example, behavioral interventions maybe listed on a separate sheet from wound care interventions. There may also be a procedures flow sheet if not integrated within another document.
Diabetic Flow Sheet
This is often separate from other nursing documentation. It is used to keep track of the patientís blood sugars, their insulin, and any snacks that may be given for the purpose of controlling their blood sugar. The administration of Glucagon, 50% Dextrose or oral hyperglycemic agents are also documented here.
Many times the patientís blood sugar, also known as a glucometer reading, may be documented in other places such as the Nursing Assessment Sheet or the Flow Record. Some nurses will write glucometer readings in the Medication Administration Record because they coincide with the administration of certain medications such as those listed above
Medication Reconciliation Sheet
This is a form which is used to document the patientís home medications when they are first admitted to the hospital.
Any medications that the patient is placed on during their hospitalization and those that are prescribed to continue after discharge are compared with the home medications. The purpose of this is to prevent duplication or omission of any medications. The Medication Reconciliation Sheet may exist as a separate form or may be integrated into an Admission Assessment, Discharge Instruction Sheet, or Discharge Summary.
Wound Care Sheet
Some facilities will have a Wound Care Sheet, which is separate from other nursing documentation. This can be used to document the presence of decubitus ulcers, surgical wounds, or any other type of lesion according to policy. The documentation may include treatment, interventions, and procedures as well as assessment. Other facilities choose to incorporate this data into an existing form such as the Daily Assessment Sheet which may contain an area for wound specific interventions and assessments.
It is important to remember that with any of these pieces of documentation that even though the facility may utilize them; any particular nurse may choose not to use it due to personal preference or willful disregard.
Because some forms are added at different times during the hospitalís history there is often duplicate charting. For example, an institution may decide to begin using a Diabetic Flow Sheet, but already have a place to document the blood sugar on the Nursing Flow Sheet. Hence, the nurse may feel that it is duplicate documentation to write the results down on both. Instead, the nurse may choose one or the other, or in some cases, an alternate choice, which may reflect what the nurse has grown accustomed to doing.
Skin Care Sheet
This document may be seperate from a Wound Care Sheet and is designed to document personal hygiene, back rubs, repositioning, bathing, oral care, perineal care, and incontinent care. All of these interventions may be integrated into a single Skin Care Sheet or separated into additional nursing flow sheets.
A Toileting Schedule is another document, which is sometimes used by nursing homes and rehabilitation facilities to document scheduled toileting times. The schedule is used in attempt to toilet-train individuals who have suffered a stroke or those who are incontinent. The goal is to establish a predictable and regular toileting pattern, which would eliminate or greatly reduce the incidence of incontinence.
These may be utilized to document the participation in certain scheduled activities. Rehabilitative and nursing home facilities often utilize such documents.
Respiratory Therapy Record
The respiratory therapy departments in most hospitals have their own Respiratory Therapy Record. It is used to document breathing treatments, oxygen settings, and ventilator settings. Some institutions will document cardiograms and arterial blood gases on these sheets as well. The Respiratory Therapy Record however, may be a part of an Interdisciplinary Team Record or Flow Sheet.
Physical Therapy Record
The physical Therapy Department has its own record to document any physically therapeutic rehabilitative treatment for strengthening or regaining use of extremities or muscle groups.
Occupational Therapy Record
Activities of daily living and the rehabilitative/restorative processes designed to assist the patient in achieving a maximum level of independence are recorded on the Occupational Therapy Record. These activities include such things as brushing oneís teeth, getting dressed and undressed, bathing, hair and brushing,.
Speech Therapy Record
Speech rehabilitation and swallowing exercises as well as swallowing evaluation studies are documented in the Speech Therapy Record. These may be performed in patients who have suffered a stroke, or for some other reason are having difficulty with speech and swallowing. These studies are used to minimize the risk of aspiration by determine the ideal consistency of foods that would best facilitate swallowing.
Recreational Therapy Record
Recreational Therapy is a form of physical therapy with the psychological added benefits of recreation.
Group Therapy Records
Any type of therapy occurring in groups such as a support group for alcoholics or those with drug addictions are recorded in the Group Therapy Records.
Restraint Order and Check Sheet
Anytime a patient requires any type of physical or chemical restraint an order must be written to specify the type of restraint to be used, the purpose and behavior which prompted the use of restraint and a time frame for restraining the patient.
A separate check sheet is used to document the monitoring the restraints safety and to assure that the patient's needs are being met.
Physical restraints should be considered only after assessment of the patient, environment, and the situation have been completed. Precipitating factors must be identified and removed whenever possible. Consultations with other health care personnel should be initiated. Interventions to relieve discomfort should be implemented and then if the patient still requires restraint, a physician's order is attained.
After restraints are applied, the use of less restrictive measures should be attempted frequently and results documented.
Contraindications to physical restraints should be considered. For example, in patients with eye or brain surgery, restraints may increase an intracranial pressure or intraocular pressure (Evans, Wood, & Lambert, 2003; Maurel et al., 1996.
The patient should have access to a call bell/light. The patient's behavior and requirement for restraints must be frequently re-assessed.
If restraints are deemed necessary, the patient, family or the patient's representative should be notified and the intervention should be explained to them. Informed consent from the patient and/or the patient's family/representative need to be obtained within 24 hours for restraints to be continued.
The patient must be closely monitored and have all basic needs attended to (nutrition, hydration, skin care, and toileting).
If necessary, to protect the patient or staff from imminent injury, restraints may be implemented by trained staff. A Licensed Independent Practitioner (physician, dentist, podiatrist) must provide a written or verbal order within one hour of application.
When a restraint is applied, several items should be documented. 1) type of restraint used, 2) explanations given to the patient and family along with the actual consent received, 3) exact times the restraint was applied and removed, 4) patient's behavior while the restraint was applied, 5) frequency of care given while restraints were applied ( assessment of circulation and range-of-motion exercises), and 6) notification of the patient's physician.
If for any reason restraints are used, they need to be removed as soon as possible after the problem behavior diminishes or disappears. Criteria for discontinuation:
Improved mental status.
Ability to comply with expected behavior.
Availability of direct supervision.
Discontinuation of tubes, drains or lines if these factored into the restraining decision.
Source: Changing the practice of physical restraint use in acute care
National Guideline Clearinghouse
Diabetic Education Record
A Diabetic Education Record is usually separate from the Diabetic Flow Sheet and is used to document patient/family teaching in regards to self-monitoring and self-administration of diabetic medications.
Patient/Family Education Record
A Patient/Family Education Record may be a separate document used for the purposes of educating the patient and/or significant other about their disease process, plan of care and follow-up. This information may be integrated into the Discharge Instruction Form. All discharge and teaching forms are valuable in assessing whether a patient received proper preparation for discharge.
Social Service Consult Sheet
Some facilities utilize a Social Services Note, others simply have their social service team document on the Progress Notes. Documentation here may pertain to safety concerns, community resources, insurance issues, advance directives and the coordination or facilitation of additional referrals.
These surgical reports are usually dictated, but in some cases may be found on a progress note. Occasionally the physician will write a brief Progress Note immediately after performing a procedure and then dictate a more comprehensive note at another time. Often Operative Reports are highly detailed and technical in nature.
(EMS) Emergency Medical Services Report
An EMS or ambulance report should be a part of the hospital record for any patient who was brought by EMS. This represents the very earliest contact the patient has had with a health care professional and can be very valuable in tracking the improvement or deterioration in a patientís condition.
This document contains a summary of the patientís history and admission, the overall course of hospitalization, including the course of treatment, response to treatment, and the patientís status upon discharge. Any follow-up planning and future care are also included. It is important to examine the discharge instructions to see if they correspond to the plan which was documented in the Discharge Summary.
These documents are usually found on a duplicate or triplicate form. A copy of this document is given to the patient. The written instructions should include information about the diagnosis, referrals with the appropriate contact information, specific medications to be taken and any continued treatments. These discharge instructions normally require a signature by the patient and sometimes by an accompanying family member or care giver, especially if the patient is not competent to fully understand the discharge instructions due to sedation or otherwise altered mental status. An LNC will look at Discharge Instructions closely, along with the Discharge Summary, and Teaching Records if a patient alleges that he was not given adequate instructions for self care and follow-up.
Common Areas of Malpractice
There are eight issues that are commonly involved in malpractice claims against family physicians:
1. Failure to diagnose or delay in diagnosing.
2. Negligent treatment involving medications.
3. Negligent management of a procedure.
4. Failure to obtain informed consent.
5. Failure to diagnose or negligent management of a fracture or trauma to the extremity.
6. Failure to obtain timely consultations.
7. Negligent obstetrical procedures.
8. Poor rapport with patients.
The most common complaints against registered nurses are:
Failure to follow a standard of care.
Standards of care are the ordinary actions which are expected from a prudent nurse when presented with a similar patient care scenario.
Failure to utilize equipment properly:
Nurses may fail to use equipment properly by using it for purposes other than what the manufacturer designed it for. This may occur due to unfamiliarity with the equipment in question.
Failure to communicate:
Communication failure may involve poor communication between a nurse and other allied health care provider or physician. This may involve a lack of communication regarding pertinent patient data such as laboratory tests and assessment findings to the physician.
Proper communication of relevant discharge instructions to the patient and family or caregiver is also vital.
Interdepartmental communication and shift-to-shift, nurse-to-nurse communication are essential to the continuity of care.
Failure to document:
Failed documentation may be the causative agent in a failure to maintain continuity of care. If a particular nurse does not pass on to the oncoming shift that the patient needs assistance when trying to go to the bathroom this could result in a patient fall and subsequent injury. In this case, the failure to document or communicate resulted in the oncoming nurse not continuing to provide the needed assistance.
Failure to document can result in nursing interventions being duplicated. If a particular nursing action is not documented, another nurse may assume that a procedure or medication was not administered and duplicate that procedure or medication. This may or may not result in patient injury or adverse effect.
Documentation should be inclusive of all pertinent patient information and assessment findings as well as interventions and communication with other medical personnel.
Documentation should also be readily retrievable. That is to say that any health care provider needing the information should be able to access that information to ensure continuity of care.
Failure to assess and monitor appropriately:
Failing to assess and monitor a patient is also frequently cited in cases of nursing malpractice. Assessment and monitoring are based on nursing judgment. Although an order, policy, or standard may exist specifying how often a monitoring task should be performed, ultimately the patientís condition may or may not warrant a different approach.
Failure to assess and monitor, like any other nursing intervention, is judged by what an ordinary and prudent nurse would do under similar circumstances.
Failure to report significant findings:
Reporting significant abnormalities and changes to the appropriate physician and documenting the interaction are a vital part of the nursing process. In the absence of a physician, nurses function as the hands, eyes and ears of the physician, and must keep him apprised of significant findings.
Failure to act as a patient advocate:
Patient advocacy plays a significant role in medical malpractice claims against nurses. Usually this relates to clarifying or questioning a doctorís order which seems inappropriate at the time, in relationship to the patient assessment or presenting complaint.
It can also mean failing to request an appropriate transfer or bringing to the doctorís attention the fact that the patient wishes to go somewhere else for treatment.
In order to effectively act as a patient advocate the nurse may need to activate the chain of command within the institution if he/she is not able to get the results that the patient requires or requests.
Improper delegation of tasks:
With the increased use of ancillary medical personnel and unlicensed nursing assistants, improper delegation of tasks has become an issue in litigation as well. Nurses may, and do delegate certain tasks on an everyday basis. State nursing boards regulate which type of tasks can be delegated to other personnel.
Proper task delegation requires appropriate task analysis and evaluation of the abilities of the delegate.
The six rights of delegation:
The right type of task is delegated to the right individual to be performed at the right time.
The individual is given the right information about the task, the right supervision in performing the task and the right follow-up to assure that the task was completed properly.
Note that delegation must also be done by the right person. In other words, a respiratory therapist cannot delegate to a nurseís aide. The right person also means that the person delegating is in a position to properly evaluate the competency of the delegate and perform a proper task analysis.
It is estimated that system errors within a facility contribute to about 30% of settled claims and 32% of those are medication related errors, 27% communication errors, 18% health care associated infections, 13% medical records errors and finally 5% identification errors such as wrong surgical site and 7% other.
To better understand why medication related errors are such a problem, we need to analyze the process involved from the point when a physician first decides to order a medication or treatment to the actual execution of that treatment or medication. In the typical hospital setting there are various scenarios that can take place.
First, the physician could decide to write an order and not mention this to any of the staff. He simply places the chart back on the rack without flagging it. At this point, if he does not flag that chart, no one knows that a new order exists. It will not be discovered until someone picks up that chart and looks at it. For this reason, facilities have implemented a 24-hour chart check or even an 8-hour chart check in some places.
The process requires a nurse to look at the orders that were written over the past 8 or 24 hours and make sure that they have been noted. Noting an order, simply means that a nurse has noticed the order and begun to implement the process by which that order is executed. During a chart check the nurse looks back to the last time a chart check was performed and begins from that point forward to see if there are any orders which have not been noted. If all of the orders have been noted the nurse simply writes 24-hour chart check completed, with a corresponding date, time and signature. Anything that had not been noted would be noted at that time.
In this first step, if the physician neglects to flag the chart or bring it to the attention of a staff member that he has written a new order, the order may be undiscovered for many hours and cause a significant delay in treatment.
In a second scenario the physician writes the order and flags it appropriately. The order is soon noticed by a unit clerk/secretary if the unit happens to have one. Many hospitals do not use a unit secretary on off-shifts and rely on the nursing staff to do secretarial duties as well as providing patient care. In this scenario the patient order is soon discovered by the unit secretary who initiates the order and brings it to the attention of the primary nurse. The primary nurse then notes the order, signing off on the fact that (a) he/she is aware of it; and (b) that he/she has begun the implementation process.
The implementation process differs for different types of orders. A medication order may require that a copy of the order be faxed to the pharmacy department, called in, or delivered somehow to the pharmacistís attention. The pharmacist will place this order on the patientís generated Medication Administration Record. In the meantime, the nurse will handwrite the order on the MAR and administer the medication appropriately. A delay may occur here if the medication is not readily available on the nursing unit. It may need to be delivered from the pharmacy.
In each step so far we have assumed that the correct patient has been identified all along the way, i.e., the doctor picked up the correct chart and wrote the intended medication on the correct patient. The nurse read the medication correctly, identifying the correct patient and transcribed that information on the correct patientís MAR. The nurse then obtained the correct medication and administered it to the correct patient.
It may seem fundamental, but these various steps are filled with opportunities for error.
On any given shift the nurse is distracted and pulled in many directions at the same time. On a busy unit the nurse may not have an opportunity to look at a chart for quite some time. When the nurse does pick up the chart it is possible that the phone will ring and a patientís call light will go off at the same time. The telephone call may involve another patient and require that the nurse pick up that other patientís chart to provide the information being requested on the phone.
In the meantime, a family member may come up to the desk and ask for their family member to be medicated. Simultaneously someone else may come to the desk and report that their mother just fell on the floor.. With no one else around, the nurse may need to leave the desk in order to attend to these patient's needs.
Perhaps 20-30 minutes later the nurse might make it back to the desk. Now he/she has to pick up the correct chart again and start the process where she left off. Upon arriving at the desk the nurse may be confronted by a physician asking for information on yet another patient and then a nurseís aide requesting pain medication for someone else. All of these distractions can either delay the processing of the order, which the nurse was working on, or result in the nurse forgetting all about the initial order because of other pressing needs. Even worse yet, the nurse might process that order on the wrong patient.
Add some illegible handwriting, similarly pronounced and spelled medication names and the potential for error is compounded further.
A study released in 1990, which was commissioned by the State of New York, showed that adverse events or injuries from medical interventions occurred at a rate of about 3.7%. The percentage of adverse events which was attributed to negligence was 1%. Only 1 in 8 individuals who suffered from an adverse event due to negligence actually filed a claim. One in 15 received compensation. Most adverse events resulted in only minimal and transient consequences. Most of the patientís medical expenses were paid for by the health insurance. Thus only a handful of patients who were injured as a result of negligence actually filed a medical malpractice claim. A significant portion, approximately 22% of those who did not file a medical malpractice claim, suffered moderate to great incapacity.
A study released in 2006 involved over 47,000 claims, which represented about 4.5 billion dollars of incurred losses showed that the claim frequency was stabilizing with an average size of claims continuing to increase at a rate of 6% a year. Although the amount paid to plaintiffs increased by only 3%, the amounts paid to defend against the malpractice cases rose by about 17%. Health care facilities are spending more money to aggressively defend malpractice claims. Overall fewer malpractice claims are being filed, but the dollar amount of each claim is increasing.
Legal nurse consultants can play an important role in determining the merits of a medical malpractice claim. Legal nurse consultant services can include:
1. Chart organization and Bates stamping or indexing of medical records.
2. Identifying missing medical records.
3. Transcribing or translating illegible records verbatim.
4. Generating a chronological report, which highlights and summarizes the significant events.
5. Identifying the proximate cause.
6. Identifying the strengths and weakness of a particular claim.
7. Conducting necessary medical literature research.
8. Identifying and locating the appropriate experts for expert testimony.
9. Reviewing opposing expertís reports and depositions and preparing interrogatories.
10. Contacting and interviewing appropriate witnesses.
11. Preparing witnesses for depositions by the opposing attorney.
12. Preparing a written expert report and opinion.
Chronologies are especially useful when reviewing a complicated case with multiple health care facilities. It allows the attorney to condense hundreds or even thousands of pages of medical documentation into a legible and smooth flowing report highlighting the significant events that transpired during the hospitalization.
Occasionally it can be beneficial for the attorney to have a legible tranion or translation of a physician or other health care providerís notes, which are difficult to read because of unfamiliar terminology, abbreviations and mostly illegible handwriting.
Solid expert opinion should be based on common practice, experience and research as they pertain to the uniqueness of each case. Nursing and medicine do not follow recipes which can be applied in every situation. Text books, guidelines, protocols, established policies and procedures within a given institution may or may not always be applicable to a particular patient care situation.
Because every individual is unique, every case is different and mandates individualized evaluation. Each patient brings with them their own unique co-morbidities, medical history, family history, social history, allergies, current medications and variability in their presenting complaint as well as variable individual responses to medical interventions. Any given standard may require modifications in order to suit the uniqueness of the patient's needs. Standards should be understood as guidelines rather than absolute mandates.
Every case and the applicable standards must be evaluated in context. The expert is able to evaluate the specifics and determine the course of action that should have been taken by an ordinary, prudent health care provider, when faced with the same patient care scenario.
The ideal expert will have similar qualifications as the individual who provided the health care in question. It is important to remember though, especially in nursing, that most of the issues involved in a claim as previously discussed constitute very basic concepts which are universal to all areas of nursing.
Remember that the nursing process involves assessment, nursing diagnoses, outcome identification, planning, implementation and evaluation. The fundamentals are:
1. Providing age appropriate, culturally and ethnically sensitive care.
2. Maintaining a safe environment.
3. Educating patients about their health care practices and treatment modalities.
4. Assuring continuity of care.
5. Coordinating care across the settings and among different caregivers.
6. Managing patient information.
7. Communicating effectively.
8. Properly utilizing technology.
These are straightforward and basic concepts that span all areas of nursing. For this reason, it may not be necessary to have a neurological trauma ICU nurse to identify a breach in the standard of care which involved failing to notify the physician of an adverse patient event. Often times the medical record review is best served by a well-rounded nurse who is familiar with the overall process of patient care in a variety of patient care settings; someone who not only know patient care but understands the overall system.
Reviews are mainly conducted for the purpose of identifying merit and causation. The initial chart review by a legal nurse consultant should be able to identify the strengths and weaknesses of any particular case along with any deviation from the standards of care. The legal nurse consultant may also serve as the expert for the particular case in question or identify a more appropriate expert for the case.
In claims which involve a physician, the testifying expert should always be similarly trained, similarly experienced, and practicing in a similar setting as the actual health care provider in question. For example, a Harvard trained cardiologist working in a large city hospital who sees approximately 50 patients per day is not the best expert to evaluate the care, which was provided by a family practice doctor in the panhandle of Oklahoma at a 50-bed hospital where he only sees a handful of patients per day.
A good expert report should always be factual, concise; easy to read and understand. The expert must be able to take the complicated medical record, which is full of scientific and technical jargon and translate the events that transpired into simple English which can be understood by the average juror. If the expert is unable to effectively communicate his opinions and the reason for his opinions then he will be ineffective regardless of his qualifications.
A medical record review can be very time consuming, especially for the non-medical paralegal or junior associate. The reviewer must be familiar with standards of care and how to apply them in the case before them. He/she must locate and interpret pertinent information, and be able to identify when parts of the record are missing. Missing documents are a common problem. Sometimes they contain critical information that may affect the merits of the case.
Insurance Information Institute
Oklahoma Nurse Practice Act
Oklahoma State Board of Nursing
Scopes and Standards of Practice
American Nurses Association
Protecting Yourself From Malpractice Claims
Reising, L. and Allen, P.
American Nurse Today
Copyright (2008) Legal Medical Resource Group L.L.C.
ABOUT THE AUTHOR: Louis R. Sanchez RN, BSN, CLNC.
Since graduating from Rhode Island College with a BSN in 1987 I have practiced nursing in a variety of clinical settings. My experience includes emergency, critical care, medical-surgical, telemetry, home health, IV therapy and hospice. I also have valuable experience in nursing education and management.
As a Legal Nurse Consultant experienced in working with plaintiff and defense attorneys, I have found that some attorneys will spend countless hours trying to decipher the contents of a patient's medical record before contacting an LNC.
More often than not the consultant can determine the applicable standards of care and thus merits of the case in a fraction of the time. Ultimately an experts review will be needed to confirm or dismiss any suspicions of malpractice and make sure nothing has been over looked.
Copyright Legal Medical Resource Group L.L.C.
More information about Legal Medical Resource Group L.L.C.
Review of the Medical Record for Medical Malpractice
By Legal Medical Resource Group L.L.C. Legal Nurse / Medical Consultants and Expert Witnesses
Call Louis R. Sanchez RN, BSN, CLNC. at (405) 979-0548
Review for Merit & Causation: The review of a patientís medical record can be a complicated and daunting task. The documents are different from institution to institution.
While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer. For specific technical or legal advice on the information provided and related topics, please contact the author.