The quality of nursing documentation … Record keeping is an essential part of nursing practice with clinical and legal significance. Communication problems happened between providers, as well as between providers and patients. Illegible Records. Also, patients generally interact with healthcare providers under crisis or high-stress conditions. One of the most famous cases in medical history that led to regulation of the number of hours that resident physicians are allowed to work is also a case study in clinical documentation failures. We don't know whether the nurse(s) responsible for the patient actually did perform the ordered leg examinations, because the supporting documentation didn't exist. A Case of Missing Documentation : […] In the words of a 2014 study published by the medical journal BMJ Open, “Managers in healthcare have a legal and moral obligation to ensure a high quality of patient care and to strive to improve care.”. Quality of care and safety are the highest priorities for professionals in hospital management. Poor conformance of medical care to quality metrics has been demonstrated in other areas, such as chronic kidney disease, when data were retrieved from claims databases. The patient's vital signs were not taken every 10 minutes (as specified by hospital protocol for patients on nitroglycerine drips). The only proof of this is through nursing documentation. “No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility if you’re ever involved in a lawsuit” (Austin, 2010). However, documentation of CHF alone in the inpatient setting would not impact the DRG relative weight unless the acuity and type of heart failure is noted in the documentation. sible for ensuring safe, quality patient care. Documentation and Data Improvement Fundamentals. By Mary Butler. Ruthann Russo, JD, MPH, RHIT . Introduction. The most common provider-to-provider communication breakdowns were: miscommunication about the patient’s condition; poor documentation, and; failure to read the patient’s medical record. The patient sued, and the hospital had to pay her $1.5 million in damages. Failure to document a patient’s condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and the nurse(s). Let’s look at an example. Ensure that staff are documenting the patient’s statements and actions in the medical record and on the care plan in order to give insight into the state of mind. Doctors are notorious for poor handwriting and the point of many jokes. The importance of proper documentation in nursing cannot be overstated. Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care. Poor services, at stressful times, will negatively impact patient … The patient suffered nerve damage after a massive clot was removed in the external iliac artery. It may be difficult to sustain a positive mindset while scheduling a doctor's appointment, getting an X-ray or awaiting lab results. The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and gross revenue for the healthcare organization. In some cases, a combination of both issues caused patient harm. Preventing Healthcare's Top Four Documentation Disasters. The serial documentation by the nurse attending the patient in the ED was not consistent and included a gap in documentation of vital signs from 4:36–5:05 p.m.; further, nothing was documented from 6:50–7:49 p.m. Always indicate who provided care to the patient and include a signature recording the author of the entry. Entries for Care Performed without Signature. The decisions made and actions taken by hospital managers have a direct effect on patient care. This is a good example of a time when documentation may impact the patient’s disease burden representation in one setting but not another. Even if you are a solo practitioner, it is good practice management to initial the daily note.