Documenting Nursing Assessments in the Age of EHRs By Georgia Reiner
As you embark on your nursing career , you will grow accustomed to documenting patient assessment results in the electronic health record ( EHR ), rapidly clicking responses to assessment checklist questions . However , at times nurses complete these actions without giving enough thought to their documentation because they want to move on to their “ real ” work : caring for patients .
The danger of this approach is threefold . First , nurses might base their assessment on the checklist not the patient . This can lead to an incomplete assessment , especially if the nurse inadvertently clicks something as being done when it hasn ’ t . Second , nurses might fail to adequately document a finding if it does not match up with the available options in the checklist . Third , nurses might fail to document assessments when a patient ’ s condition changes or fail to document practitioner notification of the change .
All three scenarios can leave nurses open to legal action . For example , a harried nurse caring for a patient who had a total hysterectomy clicks “ normal ” as the result of abdominal auscultation even though she hasn ’ t completed this assessment and misses the absence of bowel sounds . Soon , however , the patient develops vomiting and severe abdominal pain and is diagnosed with a bowel obstruction . This nurse could be held liable for the delay in treatment .
Dangers of improper documentation Nursing students are taught that documentation is a vital nursing responsibility . It ’ s important for planning patient care , communicating with providers , and demonstrating compliance with federal , state , third-party , and other regulations . But what you may not have learned yet is that documentation issues can result in professional liability lawsuits or the State Board of Nursing ( SBON ) taking action against a nurse ’ s license .
NSO and CNA ’ s
Nurse Professional Liability Exposure Claim Report : 4th Edition found that documentation deficiencies are contributing factors in many nurse professional liability claims , and that the average total incurred for claims involving allegations related to documentation deficiencies was $ 238,761 . The same report also noted that 9.7 % of all license protection matters , which involved defending nurses during SBON inquiries , were related to documentation . Of these , nearly half ( 49.6 %) involved an allegation of fraudulent or falsified patient care or billing records . Failure to document treatment / care as required by regulatory agencies or organization policy comprised 28.6 % of matters related to documentation , followed by documentation that didn ’ t accurately reflect patient care and services ( 12.8 %), failure to properly correct documentation errors according to organization policy ( 5.3 %), and inadequate or untimely documentation ( 3.8 %). These SBON matters serve as reminders of how nurses need take time to ensure they are completing documentation properly .
Benefits of EHRs You may hear some nurses express negative views about EHRs , including that they ’ re cumbersome and can take nurses ’ attention away from their patients . But it ’ s important for nursing students to understand that a well-designed EHR has several benefits , including improved efficiency and quality patient care . For example :
• EHRs provide an excellent mechanism for communicating with a variety of healthcare providers in a timely fashion , thereby improving care coordination .
• EHRs can incorporate guidelines , reminders , and decision support tools that can help providers make better decisions and deliver better care .
• Electronic documentation eliminates the problem of misinterpretation of handwritten orders .
• EHRs facilitate immediate access to data by multiple people in multiple locations .
EHRs also can protect nurses against lawsuits and SBON actions taken against their licenses . However , to gain the most benefit from EHRs during their careers , nursing students need to learn to take full advantage of EHRs .
28 NSNA IMPRINT • NOVEMBER / DECEMBER 2021 • www . nsna . org