Between late 2004 and early 2006, the Professional Liability staff members of Princeton Insurance have worked with client nursing managers and risk managers in a new approach to an old problem, documentation. This article will share the results of this work. The effort put into this project has set up a system that physicians can use to improve documentation in their office practices too.

Documentation as an Ongoing Issue

Medical record documentation (often referred to as “charting”) has three authoritative functions. Documentation is done as a professional responsibility, to satisfy regulatory standards, and to communicate medical information.

Healthcare professionals are responsible for keeping records of the care that is given to their patients. Clear documentation of the patient’s condition, medical/nursing decisions that are made, the interventions that are implemented as a result of those decisions, and the results of those interventions should all be found in the medical record.

Both state and federal governments have issued regulations which specify what type of documentation must be done in certain circumstances. Federal laws such as EMTALA, and CMS regulations for long-term care facilities, focus on specific areas of care. State regulations such as those promulgated through the Department of Health (DOH) are often written to cover all areas of acute care facilities.

Documentation in the record itself serves the immediate purpose of intra-staff and physician communication. In this role it becomes paramount that medical record documentation, or “charting”, be taken very seriously by all who participate in the function. Yet poor documentation chronically continues to play a part in malpractice claims.  Demanding schedules, distractions in the workplace, and a lack of comprehension of the serious nature of medical record documentation can lead writers to make mistakes they may have to live with in court.

Auditing Charts to Improve Documentation

In mid-2004 the Professional Liability (PL) group of Healthcare Risk Services updated its chart audit tool as part of the second phase of its service plan. The PL consultants began a series of meetings with nursing leaders of each insured facility. The nursing managers were taught how to audit a chart for liability issues. At these presentations each nursing manager brought a chart from his or her own area. The program included instruction about the audit tool and general principles of charting liability. After this initial introduction the nursing managers reviewed the chart they had with them, using the Princeton PL tool.

All of the nurse managers were very comfortable reviewing charts, but were more accustomed to searching for quality or utilization indicators. Looking at a chart in this distinctly different way gave rise to many discussions. In some cases the managers discovered changes that they wished to make in forms or in processes that their facility used. In some cases, the managers found examples of very good documentation that they could build on with their staff. In many situations, however, they found repeated instances of poor documentation which could lead to medical errors and increased facility or individual liability if a claim were made.

The Audit Tool

The audit tool itself was set up to look at a variety of common charting problems which appear with varying frequency in liability claims. The audit tool provides forty-five different special areas of a routine chart to review. It also has four specialty areas, Behavioral Health, Emergency Department, Obstetrics, and Oncology to review since these areas often have very specialized documentation of their own. Specialty nurse managers who audited their own area charts focused more on their specialty portion of the audit and only reviewed a portion of the forty-five specific questions for a typical medical-surgical chart.

While this proved to be a very rigorous project for the nurse managers, and took more of their time than the PL group would ordinarily schedule, it had a long-lasting impact on the documentation processes at a number of facilities. It was an opportunity for the nurse managers to sit down as a group and focus on the state of their medical records. The discussions the meetings engendered lead to improvements in both the records themselves and the charting processes that both nurses and physicians struggle with.