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 The Case For Nurses’ Notes

Electronic medical records have many benefits, but it is imperative to maintain written documentation to clarify actual care.

 

 
 
Implementation of electronic medical records (EMRs) in the nursing home setting is to be celebrated. As an industry, long term and post-acute care is finally catching up with the remainder of the health care industry and providing point-of-service documentation.

This type of documentation, the “check the box” documentation, however, should never take the place of a good narrative note that encompasses clinical assessment and critical thinking.

So many software programs claim to promote effectiveness and efficiency through streamlined check-the-box documentation styles. Administrators may embrace this, the business office may love it—but nurses should be cautious of it.

Skills Hard-Earned

Nurses have spent years learning assessment skills, fine-tuning those skills, moving from amateur to novice, novice to expert, and now to just checking a box? The concept of writing a narrative note, documenting clinical assessment, and critical thinking is paramount to providing the complete picture of resident care.

The act of actually writing or typing a note triggers key points to touch on in the assessment. Many times nurses don’t realize how much assessment they have done until they sit to write the note—checking the box doesn’t allow the nurse to give credit to the expert assessment skills she has developed over the years or the specific care that was given in any given shift.

As anyone who works as an expert legal case reviewer will attest, there are far too many medical records that have been rendered indefensible due to the inherent limitations of the check-the-box form of documentation.

A Case In Point: Pressure Ulcer

A family brought a claim against a nursing home for an extensive pressure ulcer located on the left hip of a male resident. It appeared from the wound care notes, and in interviews, that despite the outcome, the nursing home was vigilant in providing appropriate care and treatment to this resident’s pressure ulcer.

Unfortunately, the facility had moved to a check-the-box software, and its daily documentation did not support the care given. On admission, the facility had generated a standardized care plan for a Stage II pressure ulcer. The nurse was given the options of checking either “actual” or “potential” pressure ulcer, and under interventions was “Reposition as Tolerated.”

The admitting nurse checked “actual,” signed the bottom, and placed the care plan in the resident’s medical record. As with many nursing centers, the standardized care plans are used for the first 21 days of the stay until the individual care plan is developed. Unfortunately, this resident moved from a Stage II to a Stage IV ulcer in only a couple of weeks, resulting in this standardized care plan being the only documentation of the nursing treatment plan, except for the nurses’ notes.

What Was Missing

The care plan should have included substantial documentation in the nurses’ notes supporting an individualized repositioning program, such as the standard “Turned q 2 hours, repositioned off left side.” However, what was in the care was a standardized check-the-box software for daily documentation.

For each shift, the nurse was prompted to answer questions regarding care. In addition, there was an option of writing a nurse’s note, which some nurses did and some did not exercise, but clearly those who did write notes were the exception. The following items were checked by either the nurse or nurse assistant at each shift: pressure ulcer, repositioning program, pressure-relieving mattress, pressure-
relieving device in chair, nutritional supplement, and incontinence care.

This was the extent of the preventative nursing care documented on this pressure ulcer for two weeks. In prior years, the nurse would sit down at the end of her shift and write something like this: “Resident with a Stage II pressure ulcer on left hip. Dressing dry, clean, and intact. No drainage noted. Up in chair for meals only. Consumed 75% of dinner and 240 cc protein shake. Repositioned off left side, position changed q 2 hours. Pressure-relieving mattress in place. Resident without complaints of pain.”

An examination of this case study would find that the nursing home would have a difficult time preparing a defensible case, as the record lacked any information on how often the resident was repositioned and if he was positioned off his left side, how often incontinence care was done, and how often a nutritional supplement was given and consumed.

Case Two: Substandard Care

A family had brought a claim against a nursing home for substandard care relating to their mother who had resided in the center for well over a year. The resident had end-stage renal disease and received dialysis three times per week. This resident was completely cognitive and often refused to go to dialysis and follow her recommended diet.

Those refusals resulted in highly fluctuating weights, significant weeping edema in the legs, and, eventually, leg ulcers. The resident was clear on her wishes and could clearly understand the risks of her refusals.

The nursing home had not yet moved to the check-the-box documentation, which resulted in nurses writing narrative notes each shift for almost a year. The nurses were able to clearly articulate good assessment skills, the resident’s mood and cognitive status, the resident’s understanding of the risks, and the resident’s consistent refusal of care.

After the resident’s passing, the family contended that the resident was not of sound mind to understand the risks of her behavior.

The nurses’ notes were paramount to the facility’s defense. This center had a defensible case for this resident’s care.

Beware Of EMR Efficiencies

As the industry embraces and celebrates the efficiency of the EMRs, it should not lose sight of the reasoning behind the narrative note and the need to document clinical assessment and critical thinking.
The professional health care staff have been trained and educated to assess areas that don’t have a check box.

Staff should be empowered to document these findings, encouraging the use of narrative notes as a means to get the whole picture and trigger subtle assessment findings.

This form of documentation provides crucial information when determining defensibility of a medical record; it cannot be replaced by a check box.

Lori Shibinette, RN, MBA, NHA, is the administrator of Merrimack County Nursing Home in Boscawen, N.H. She does expert record reviews as a consultant for facilities that are engaged in liability disputes. She can be reached at lshibinette@mcnhome.net.
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