The Results of the Survey

Thirty-two facilities completed audits and submitted results for review. Although recommendations were written in all forty-five areas and three of the specialty areas, only sixteen issues occurred so frequently that they receive special attention here.

The leading two issues were illegibility and reassessment.

• Illegible charting leads directly to medical errors and makes a malpractice claim more difficult to defend. For purposes of this audit, the issue of illegibility included the use of incorrect ink color and inappropriate abbreviations as well as unreadable handwriting. Medication error cases have developed because of difficult to read physician orders. Plaintiff attorneys have the right to, and often do, ask a provider or staff member to transcribe large sections of a medical record because it is indecipherable. For a physician, this is time spent away from the practice or the OR suite; it is money lost. Sections of a medical record, blown up to posterboard size and put in front of a jury, serve to highlight illegible sections of that chart; jurors may see this handwriting as evidence of carelessness or a practitioner who was too busy to pay proper attention to detail.
   
• Reassessments should occur at specific points during the patient’s care. This is a JCAHO requirement and it represents good medical care. A patient who has been given a pain medication should be reassessed for pain relief and for fall potential.  A patient who has just had anesthesia or who has had a change in certain medications should be reassessed for fall potential. Problems can occur, however, when required reassessments are not documented in the patient’s record. This audit emphasized the fact that reassessment documentation is a weakness among caregivers. Plaintiff attorneys can make use of an undocumented reassessment if an untoward event occurs.

The next five issues to occur with great frequency were: lack of patient ID on every page; improper corrections; informed consent problems; discharge planning issues; and troubles with telephone orders.

• When patient identification data is not placed on both sides of each record sheet, a different patient’s information can be recorded on the chart. Also, if the chart is pulled apart in preparation for copying, for microfilming, or just for storage, those unmarked sheets can be lost. The lost portion of record may be crucial to a malpractice case, or future care.
   
• Corrections become a problem when they are not done as the facility’s policy/procedure requires. An unclear correction in a medical record can easily be misread by another caregiver and, if the case becomes a malpractice claim, the plaintiff attorney may try to make it appear to be an alteration in the record.
   
• Consent is a process, not just a form. With that in mind, the auditors looked at documentation regarding consent discussions in the progress notes, on the consent forms themselves, and on any other indicators of consent in the patient’s medical record. What they found was a number of issues that concerned them. Most frequently, they found consent discussion documentation missing from the progress notes or on the consent form itself, if that was  facility policy . They also noted inappropriately completed consent forms. Any situation involving a question of consent can lead both to medical error and to malpractice claims. Patients may feel they understand what they were agreeing to and/or physicians may feel that patients comprehended the situation they were in, yet misunderstandings happen frequently. Clear documentation is one way to help minimize the threat of malpractice claims in consent situations.
   
• Unclear or incomplete discharge planning records may lead to medical error and can be a plaintiff’s adjunct to the “he said/she said” battle in many malpractice claims. With little or no discharge planning recorded in the record, and only a poorly documented copy of the discharge instruction sheet given to the patient when leaving the facility, the care givers and facility are open for liability if a claim is brought. All the court will have to decide upon is your word versus the plaintiff’s recollection.
   
• Telephone orders have caused a number of problems. They showed up on the chart audit frequently because physicians did not sign the order or did not date and/or time their signatures. Physician signatures, with date and time on all telephone orders, are now mandated by CMS. This signature must be done within forty-eight hours and must be done by the treating physician or a physician who is authorized to sign for him/her. This will change the preferred practice of some physicians, but the change moves medical practice toward better patient care, better documentation of that care, and a minimization of that physician’s liability.

The remainder of the frequently noted chart review problems, and the issues surrounding them picked up on review, are listed below:

• Failing to sign, date, and/or time each chart entry 
  
• Inadequate or absent documentation of Advance Directives 
  
• Pain assessments 
  
• Patient education
  
• Treatment goals
  
• Timing (which refers to documenting the time that something happened: i.e….When was the family at the bedside?)
  
• Care decisions and treatment plans
  
• Contemporaneous charting (includes notes that are not dated and timed and notes that are not comprehensive in nature By comprehensive, the tool described a note as being fully descriptive rather than simply saying “informed consent discussion done.” This part of the review was focused only on physician areas of the record.)

Altered Records

Though they did not occur with a frequency that would qualify as the top issues for purposes of this article, it is important to note that the auditors found two altered charts during this review process. An altered chart should never exist. Alterations in the record, even when innocently made, appear to be done to cover up a mistake. No amount of explanation can clear up that perception and an altered record makes a claim very difficult to win.

Conclusion

This documentation audit is a new approach to teaching documentation liability. By showing nurse managers how to audit a chart for liability issues the PL group extended its reach to virtually all nursing staff in the participating client facilities. The nurse managers who attended the sessions were encouraged to periodically audit a chart or two with the audit tool to keep in practice and to monitor documentation in their areas. They were also encouraged to teach their staff the same audit techniques and to have individual members of their staff review one or two charts on a periodic basis. In this way, more nurses could become sensitized to the types of documentation which contribute to errors and inflame malpractice suits.

The PL staff members also were and still are involved in follow-up with managers and staff by assisting with inservices, utilizing the new Documentation ICG, and by responding to questions that have developed from individualized audits that managers and staff have done on their own. Some of the facilities took portions of the Princeton audit tool and incorporated it into their own routine audits. Some of the facilities sent in further chart audits over a series of quarters to track their progress.

Finding a way to document comprehensively and clearly is a challenge for every medical provider and staff member in an increasingly complex healthcare system, yet it continues to be a fundamental requirement of good medical practice. This project was designed to train more people in the ability to search out and promote good documentation practices. It was also designed to keep that training going so that it would not be a “one time only” experience. The audit tool can also be used by physician practices to do routine chart reviews, just as the facilities have done, so that practice documentation can conform to the best standards for the dual purposes of better patient care and protecting practitioners and caregivers from liability.