Effective Nursing Documentation

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6/17/2021

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Copyright © 2020 MyFreeCE, Inc.

Course DescriptionThis course is designed to teach the nurse the importance of proper, timely charting. Demands are ever increasing on nurse and our society has higher expectations than ever before. The goal of this module is to provide the reader with an enhanced understanding of the significance of nursing documentation. Tips to enhance charting quality and improve legibility will be presented. It is important to note that this course is to provide an overview. Each state, organization, and Board of Nursing may have different rules to follow. If in doubt, always check with your Board of Nursing.

Learning Objectives1. Identify the significance of maintaining the confidentiality of patient's medical

information and records2. Identify documentation practices which may be legally unfavorable, including illegible

handwriting3. Recall the relationship between communication and litigation4. Recall specific factors which increase the risk of litigation5. Identify integral assessment components of initial and subsequent patient assessments6. Identify positive and negative documentation practices7. Describe the Joint Commission required components of care which must be evident in

the medical record8. Identify special documentation circumstances with documentation of

pediatric/geriatric/confused patients and those with other communication/cultural barriers

9. Recognize the significance of the medical record in continuity of patient care

Nursing would be so much more enjoyable if we didn't have to do so much documentation! We could provide excellent patient care, all the teaching required to have patients understand their disease processes and treatments, time to fully explain things to family members, meds would be given on time and “please” and “thank you” would roll off the lips of patients we cared for, all of our co-workers, our supervisors, and every physician we came into contact with. There would be no such thing as malpractice, after all, we never intend for a patient to have a negative outcome.

Dream on-this is the new era of health care! Patients are hurried through the hospital or outpatient surgery setting at lightning speed leaving barely enough time for covering the basics before they are sent home to recover. Time management for nurses is a must have skill. Prioritization is a must. Yes, there is more work to be done in a shorter amount of time and with fewer pairs of helping hands. It is unforeseeable that things will differ much for nursing in the near future. How can you survive, provide excellent care, and produce documentation that accurately reflects all the time, care, and critical thinking you do for patients?

Documentation is one of the most important functions nurses perform. And yet, the task of committing thoughts and actions to paper or to the electronic medical record (EMR) is often relegated to an “end of the shift – hurry up and catch up” task. Handwriting (if it can be comprehended at all) is often sloppy, spelling mistakes are frequent, and grammar is so incorrect that even the sweetest nun would want to crack the writer over the knuckles with a ruler!

It cannot be over-emphasized-the medical record remains as the only evidence of the nursing care you have given! Think about this- in a malpractice trial will the jury be interested that your patients were always bathed by 9 am, hospital corners were perfect, or your IV tubing was neatly labeled? Not really. Forget to document assessing distal pulses in a fresh post-op fem-pop bypass patient who later has to have the leg amputated (you know you checked them, how could you forget to document them?) and there you have it - written (actually unwritten) proof that you do not deliver adequate nursing care. Not only that, but you cannot prove that you followed provider orders or hospital policy. This type of mistake makes the nurse appear unprofessional.

Nothing can be more humiliating than viewing your own nurses notes or a screen capture from the electronic medical record in a courtroom, blown up to a 3 X 5-foot poster for all to see. Nothing except the fact that even you - the author - cannot read or understand what was documented. The lawyers will ask you, “Do you have any independent recollection of my client or the care you delivered to her on (date usually several years before)?” The response will usually be “no”. So now, without recollection of your own, and a medical record which does not present itself as a good witness on your behalf, the jury is left with testimony from the patient (or family members) recollection of the event in question. It is pretty much guaranteed that they will have total recall of the event in question, and it probably will not substantiate adequate delivery of nursing care.

Even if you can explain the care you delivered, the jury may have already formed a negative opinion of you as a nurse (sloppy documentation...must also give sloppy care). You know this is just not true. The available medical literature indicates your documentation can undermine credibility and it can be a crucial component of your defense (1,2,3). What can be done to prevent embarrassment over the documentation? For one thing, electronic medical records systems are revolutionizing the way data is stored and retrieved. At many facilities, a majority of the documentation is filed away with the click of a mouse. Documenting a complete head-to-toe assessment, with all the problems on a care plan addressed, and each instance of teaching clearly documented can take less than 10 minutes (with the right training, skill, and accepting mindset – for other nurses it takes a lot longer and actually takes time away from bedside care). Yes, the computer does provide many nurses with a little relief, but not every nurse has this technology at their fingertips and even so, it’s necessary to know the basics behind those prompts that appear on the screen. This module will cover some of the basic elements of documentation, including the hospital's requirements and the Joint Commission requirements.

Some tips for use of terminology will be covered as will suggestions for documenting defensively-carefully covering all the required elements necessary for providing the expected standard of care in the community.

Nothing can take the place of nurses or their documentation. The hands-on 24-hour delivery of care in evaluating the total picture of the patient hospital stay must be clear in the medical record. The medical record, especially the nursing notes, serves to communicate information from the patient's medical, psycho-social, and medication histories. Many factors are required to be assessed for each and every patient regarding needs, care necessary to meet those needs, and what must be done for the patient in respect to continuing care after the hospital stay is over. The nursing notes must be comprehensive in nature and support and be consistent with those of other ancillary departments.

Finding Time to Document

Some steps have already been taken to minimize the time required to document routine care for patients. Depending on the facility or organization, these measures may include flow sheets for vital signs, pre-printed 24-hour assessment and admission forms, check sheets for neurological exams, procedure worksheets (conscious sedation, recovery room, OR forms etc.). Forms help to assure that at least the minimum data is always included. Regulatory agencies (such as the Joint Commission) require individualization in patient care. How then can you document individualized assessment and delivery of care with a form? It is often made possible by the inclusion of a space for narrative notes. Take advantage of this space, even if you add one or two simple sentences which contain data that makes this patient's care or needs unique.

Nurses are so busy and the expectations just keep increasing but the importance of documentation cannot be over emphasized. There are many ways to make documentation go faster, but that ease will depend on the system used by your workplace. Unless your EMR automatically identifies you as the person making the chart entry or if you are completing paper documentation outside the EMR, make sure you clearly identify that you filled out the form by including your initials, signature, or both, as required, depending on the form. Sounds almost insulting to remind nurses to sign their work. When reviewing medical records of discharged patients, however, nearly every medical record contains at least one form or check sheet where the person making the assessment or documenting care is not identified.

Integrating your documentation with your care delivery requires multi-tasking. Nurses make use of every second of their time. Below are examples of multi-tasking.

You assist a patient to the bathroom who will need help getting back to bed. You know it wouldn’t be wise to leave him unattended, so you remain outside the bathroom door. Grab the clipboard or if you use a mobile EMR device and fill in your assessment at this time.

Combine care delivery with history taking, teaching, and assessment. During a bed bath, nurses often engage in conversations with patients in which the patient expresses health care needs and concerns. Take a few moments to document concerns, needs and your teaching down, while they are still fresh, maybe even during the few moments when the patient is encouraged to perform an aspect of care for themselves (such as brushing their teeth).

Giving medications and performing treatments present opportunities for nurses to assess, plan care, and teach. However small you may feel the interaction, take credit for any instruction provided and add it to the medical record while it is still fresh in your memory.

Let’s take a look step-by-step at some tips and strategies to improve the quality of the documentation you produce, the usefulness of your documenting to others who provide care to the patient, and components of a sound medical record and their significance.

Take it from the Beginning

The initial assessment must be clear, comprehensive and reflect a sound understanding of the nursing process to deliver the most appropriate care individualized to a specific patient's needs at that particular moment in time. Prioritization and critical thinking must be evident. Details must be included... otherwise, how can comparisons be made regarding improvement or decline during the course of care delivery? Some examples:

If you don't clearly identify the location, size, depth, drainage characteristics, integrity of tissue margins (etc.) of the pressure ulcer that a nursing home resident arrives with, on discharge, it must be assumed (by the ever-important reader of the chart) that this ulcer developed in the hospital, or was made worse, as a result of poorly delivered care!

If you don't document that you instructed the patient not to get up to the bathroom without using the call light, and that the bed was left in the lowest position to the ground, when he falls and fractures a hip, you have no evidence that steps were taken for the patient's safety to prevent falls.

If you don't document that despite giving wound-care instructions to a patient he states he is “still competing in a surfing competition tonight” after 38 sutures have been placed in his thigh - when he returns in three days with cellulitis you have no record of intended patient non-compliance which may have contributed to the problem. Worse yet, measures you took to prevent this negative outcome would not be evident.

If you don't document exactly the reason why (usually best done in the patient’s own words) a particular medication or treatment is refused, a negative outcome could be blamed on poor nursing teaching regarding the importance of the medication or the treatment. For example, Mr. Dysphagia states “I cannot swallow pills” and you chart “instructed regarding importance of taking potassium replacement, with understanding verbalized. Call to Dr. Smith to notify and request liquid or IV Kcl alternative” provides a

much better defense than “patient refused” simply written on a medication administration record when Mr. Dysphagia has a cardiac arrest because his potassium level was 1.2!

Simply put, you are on a fact-finding and reporting mission. A complete medical record entry contains the following:

Identification for whom the data is about (usually done by a key plate imprint on paper charts, a sticker, or a pre-printed documentation sheet or via a unique electronic medical record identifier for EMRs)

Date and time of the assessment or intervention The assessment of the problem, knowledge deficit requiring teaching, patient concern

etc. The assessment contains subjective (what the patient says or thinks) and objective data (what you observe).

Statement of the problem or knowledge deficit (usually a nursing diagnosis), formed after needs have been detected

Measurable goals derived from the nursing diagnosis Implementation measures: interventions taken to correct the problem or knowledge

deficit Evaluation of the patient’s response to interventions or teaching – clear, measurable,

understandable, and preferably consistent between caregivers Your identification as the creator of the entry by signing or initialing as required. This

may include adding one’s title.

Some of the data can be contained within a check-off sheet or inventory, some cannot. Use your nursing judgment when additional data should be included in a narrative format in addition to forms or check-off sheets.

What About Flow Sheets?

Flow sheets (both written and electronic) have positive and negative features when evaluated from a documentation quality perspective.

Positive features of documenting with flow sheets or a check-off type documenting sheet is obviously the time-saving aspect. They are quick to fill out, decrease the duplication of data, and they are structured and organized. This format of documenting serves well to eliminate personal bias and permits precise measurements, usually by the use of measurement scales that are described clearly on the form to enhance accurate recording of findings in a manner which can be compared regardless of the nurse making the observation. They are excellent for recording repetitive data, such as vital signs. I&O, and routine care, such as ADL's. Many smaller healthcare sites, such as nursing homes, or individual healthcare provider’s offices may still not be using electronic medical records.

Negative aspects of the use of flow sheets as the primary form of recording nursing documentation include their pre-printed format which is standardized and impersonal. Nurses must often select one answer choice which “best fits” the patient or “comes close” but doesn't fully explain or describe what actually is unique to this patient, whereas a narrative note would. Often, when using flow sheets, nurses forget to document the responses to their interventions or teaching given. When questions do not apply to a patient, nurses often forget to cross out the space or indicate N/A. This presents a potential problem for documentation to be altered or added to at some later time, thus affecting the credibility of the medical record.

Most flow sheets have space for narrative findings. When appropriate, this space and additional space on nursing notes must be used to paint the clearest picture of what is going on with the patient.

An important note on providing more documentation or adding additional pages with paper documentation, always indicate near the identification spot of the form note or paper, what number your note is if there are more than 1 (such as: page 1 of 2). Be sure to end one page of a continued page with your signature and “note continued on page 2 of 2”. Begin the top of the new form with “continued note... Date/time etc.”

Things to Remember

The medical record serves as the most important witness in a medical malpractice or negligence case. The worn-out phrase “not documented... not done” rings with a much more somber tone when you answer your home doorbell at 6am and are handed a subpoena in which you are being sued for malpractice!

Most lawsuits revolve around simple acts and basic care rather than complex equipment or procedures. No detail of the patient's care delivery is too insignificant to document, particularly if you took the time to assess or notice it in the first place.

Common reasons for lawsuits involving nursing care include:

Failure to question inappropriate physician orders Failure to adequately monitor a patient Failure to protect the patient from an avoidable injury Failure to document care that was given in an adequate manner Failure to properly administer medications Failure to take a complete and appropriate nursing history Failure to follow orders correctly and timely Failure to perform procedures properly Failure to protect patient confidentiality Failure to assess an emergency situation properly and initiate appropriate resuscitative

measures

Functioning outside the scope of nursing practice Failure to request help when the nurse is unable to meet the needs of a patient Failure to notify the physician of test results Failure to follow hospital policy and procedure when restraining patients

A Few Words About Incident Reports

The incident or occurrence report is a communication tool used by the risk manager to evaluate any unforeseen or unintended outcome that happens to a patient or visitor. It allows collection of important information that can be assessed as a means to determine what caused the event to happen and what can be done in the future to prevent similar situations from happening. When a lawsuit is anticipated, an incident or occurrence report helps the legal team to assemble their defense.

Some tips to remember when filling out an incident or occurrence report…

Be completely objective, do not include speculations Do not admit liability or cast blame Avoid finger-pointing Incident reports are typically considered “not discoverable” in a lawsuit, but if they

somehow fall into the hands of the plaintiff’s attorney because they are mentioned in the chart, the case may be as good as closed

Do not speculate on how to change the problem or avoid it in the future (“If we installed a light in the area, people would see better and not trip”)

Do not indicate that the incident is not the first time this problem has occurred Use patient quotes when pertinent (Mr. Smith stated “I will not call for help when I need

to stand and urinate…I’m not a child”) Include your first-hand observations only - report what you see, not what you think

happened or what caused the incident, unless you directly observed the incident as it occurred.

Why So Much Fuss About Documenting?

The medical record is reviewed by many other individuals than nurses, doctors and persons from ancillary departments.

Documenting is a professional responsibility which serves to evaluate the effectiveness of care and treatments. It serves to enhance continuity of care for the current and subsequent admissions.

The medical record may be scrutinized for the provision of service and use of supplies by insurance companies or Medicare/Medicaid to evaluate for errors in billing or fraud. Again, "not documented, not done" holds true. If you don't chart that an infusion pump

was used to deliver the IV fluid, there's no evidence to support billing for use of the item! (same goes for restraints, mobility devices, specialized beds or equipment, solutions and supplies used for dressing changes, etc.).

Length-of-stay justification for some patients may still be required to be supported by documentation in the medical record – if your documenting does not reflect that a diagnosis or disorder is correct, the hospital could lose money, or worse yet, be accused of fraudulent billing practices (for example, the patient medical record for a diabetic reflects a diagnosis of peripheral vascular disorder. You chart “Pedal pulses intact” but you forget to chart that they were “by doppler” and that the “feet remained slightly cool to the touch”. The reader of the medical record is left to assume that the patient’s feet are fine and the diagnosis is not correct or the problem is not causing the patient any difficulty during this particular admission.)

Quality of care assessment for hospitals is made through chart review by accreditation organizations. Poor documentation reflecting poor care delivery can impact the hospital's reimbursement (through loss of accreditation), and ultimately your paycheck.

Risk management reviews documenting to evaluate safety concerns, changes or improvements in policy and procedure which should be considered and other factors which affect the potential liability of the hospital in a lawsuit situation.

Timely, accurate and concise documenting serves to protect hospitals and nurses in the event of a lawsuit. The medical record stands as written accountability of the care you have provided and the actions taken on behalf of the patient.

Nurse, Detective, or Both?

Documenting a thorough assessment takes a bit of digging. When a patient responds that he “does not smoke” probe further - (did you ever smoke? When he responds “two packs a day for forty years ...until last week” you'll be glad you did). When a patient states an “allergy” to a medication, probe further- what happened? Did he simply get diarrhea after taking that lactulose or did he develop a rash and stop breathing when he took amoxicillin?

Barriers to assessment and care delivery must be addressed and overcome as much as possible. Language/educational level/developmental delays are not acceptable reasons for not assessing and gathering history and information. Enlist the help of others and make the physician, nurse manager or nursing supervisor aware of the less-than-optimal situation to evaluating the needs of the patient.

When you do use an interpreter to obtain data, be sure to identify this person in your notes: “patient speaks only Chinese, translation provided by pt. daughter, Connie''. Be sure to obtain and document permission to communicate through the use of a translator, for reasons of confidentiality. This is especially important when discussing sensitive issues or delivering unhappy news.

Data obtained from someone other than the patient must be clearly identify the source:

“Mr. Jones, aphasic after being struck on the head with a boulder, admitted 2:20pm to room 214 - medical history provided by Pt. wife, Wilma."

Much like a detective, you must be a master of keeping secrets. Patient confidentiality, especially in the computer age, presents a potential for leakage of sensitive data which could cause harm to the patient either financially, emotionally, or cause damage to their reputation. The Health Information Portability and Accountability Act of 1996 (HIPAA) now dictates that privacy measures be implemented and followed by every person who has access to private medical information.

Subtle physical and mental cues that you observe should also be documented. Often these serve to coordinate the care required at discharge. A patient may not tell you outright he is homeless and has no way to care for his dressings or colostomy after discharge. He may not share with you that he has no money to buy the insulin he needs. But you can observe: poor hygiene, poor dentition, and evidence of malnutrition such as clothes/shoes that do not fit properly, belts which have been adjusted down or holes added to fit a shrinking waist, hair loss etc. These cues are invaluable to share with social service or case managers, with whom the patient may feel comfortable discussing these problems, as they can assist in locating available resources.

Nursing Documentation Must Contain:

Physical / psychosocial / social assessment to determine the need for care and the frequency of additional assessments

Assessment of patient nutritional assessment Assessment of functional abilities/status to determine the need for post-discharge

planning and rehabilitation

The documentation must reflect:

Age-specific and appropriate assessment and interventions Assessment of cultural-specific needs (4) On-going assessment of educational needs Involvement of family and/or significant others when appropriate Adjustments in the plan of care as required by identified changes condition or diagnosis Continual assessment of discharge planning needs

Basically, all your entries must reflect:

The care you have given Adherence to the physician orders/plan of care

Care consistent with the community standards of care (your care as demonstrated by your documenting will be measured against what any other educated and prudent nurse would have delivered to the same patient in the same care situation).

Thoroughness in assessment is important. The pneumonic "P-Q-R-S-T" is useful for many nurses to remember to be complete in assessment of a patient symptom.

Assessment tips follow to expand your critical thinking and improve the content of your documentation. They are not specific to any one area of nursing or any one type of patient. “Triage” means sorting, prioritizing and assessing. In a sense, you “triage” your patient

assignment each time you go on shift and base your work and care priorities upon what you perceive that the patient's needs are.

Medication Tips

On all prescribed medications, obtain the name/dose/schedule Do not assume patients are actually taking a medication that was prescribed - ask when

their last dose was Also be sure to ask about “borrowed” medications they may have used from family or

well-meaning friends “with the same problem” Ask about over-the-counter medications taken: what/why and when as well as the time

last doses were taken Remember to ask about vitamins and herbal supplements and natural remedies

Assessing the patient’s medications used at home is not only desirable, but it is now a requirement that medications given at home be reconciled with what is given to the patient during a hospital visit and hospital meds reconciled with home meds upon discharge. These steps have been proven to reduce medication errors (5,6,7,8,9)

Additional Medication Documentation Tips

Don't forget to clearly identify the route/site of meds...especially the IM ones, by muscle or anatomical location (right deltoid…NOT arm; left upper outer quadrant…NOT left buttock)

Carefully document the IV site condition and patency, particularly before infusing medications which have a high potential for causing phlebitis or severe tissue injury with infiltration (such as chemotherapy, phenytoin [Dilantin], Kcl). The same rule applies if the patient is to have a diagnostic test requiring contrast dye injection.

Careful observation must be documented for delivery and possible reaction monitoring of any medication to the very young, the very old, patients with poor or absent protective reflexes (such as those consciously sedated, aphasic, post-ictal, intubated, or receiving neuro-muscular paralytic agents such as Pavulon [pancuronium] or succinylcholine [Anectine]) as these patients may be unable to tell you a problem is occurring.

Negative outcomes do happen. Phlebitis may develop even with a newly placed and patent IV. Carefully document the discontinuation of the IV, measures taken to provide comfort and safety to the patient, and notification of the physician or advanced practice clinician managing the patient. Restart the IV site (preferably in the other arm). Starting a new IV in the same arm is not advised unless you have no other option. To do so, you would have to apply a tourniquet to an already compromised limb. If the outcome is negative (loss of limb or function), your action could be seen as contributing to the outcome rather than as a measure to correct it. In some circumstances when another site is not available the patient may need a central line.

Be consistent with evaluating and documenting patient responses to medications, particularly PRN ones and especially the first time a medication is ever given to a patient!

Let’s Get Specific!

In documentation, details count! Documenting vague data or incompletely describing a finding requiring more details to justify an intervention that was taken is a dangerous pattern to fall into. Failing to take and record a complete history can be fuel for a lawsuit (10). For example:

You have concluded that Mr. Hunter is having pain in his chest (because he said so and he is three days post-thoracotomy). You decide to medicate Mr. Hunter for his pain with Vicodin ES PO. You prudently chart:

“7/7/10, l0am: Mr. Hunter complained of chest pain. Vicodin ES PO given as ordered. Pt. Also instructed to splint chest wall incision with pillow for comfort. Bed in lowest position, call bell within reach. Mr. Hunter verbalized understanding of not ambulating alone after pain medication, stated: "I will call for help if I want to get up'”.

Sounds pretty thorough, right? Being the consistent nurse you are, forty minutes after you have medicated Mr. Hunter you go to assess his pain relief. A futile act, since Mr. Hunter is dead.

You see, Mr. Hunter's pain was not related to his surgical incision. He was having an MI. Had he been on a telemetry floor, the monitor tech would have advised you he was having runs of ventricular tachycardia and that his t-waves were taller than his QRS complexes. You had no control of the patient being assigned to a non-monitored floor. What you did have control over, though, and neglected to do, was take a complete assessment of the patient's pain.

Had you questioned Mr. Hunter using the PQRST pneumonic, he might have told you that “this pain is very sharp", #10 on a scale of 0-10, radiates down his left arm and to his jaw” (his thoracotomy was on the right).

Had you evaluated physical cues, you would have noted: the condition of the incision site (staples intact, no drainage), the moisture & color of the patient's skin (he was a little pale and diaphoretic now that you think of it), vital signs (big mistake not to include assessment of these ...he was hypotensive at 88/42 and had bradycardia at 50).

Given this information, instead of reaching for the Vicodin to eliminate the patient's symptom of pain, you would have been making STAT calls, obtaining and EKG and a pulse oximetry, and preparing to transfer the patient to CCU – or you would have called 911 for transfer out of your facility if you do not provide acute emergency or critical care.

Medicating the patient for pain is the most frequently given reason for use of a PRN medication (followed closely by fever which much the same as pain described in this scenario always warrants an investigation as to the source as missed identification and management of sepsis is a huge source of malpractice litigation). Remember, pain is a natural response of the body to alert an individual that something is wrong. Do not fall into the trap of assuming that pain is always caused by a presenting problem, illness or injury. When patients are in situations of compromised health status, the likelihood of other complications occurring is high.

Be sure your assessment of the most likely cause of pain or any other symptoms is complete BEFORE you decide to medicate away or cover this protective reflex message the body is sending.

Pain documentation is especially crucial when opioids are administered, especially on a long-term basis. Their appropriate use and the adequate relief of pain in a patient with a chronic or terminal condition while in no way being misconstrued as promoting substance abuse must be clearly identified in the medical record (11).

Outcomes

More now than ever before, the adequacy of the care we provide is being measured in terms of outcomes, how the patient is after care in relation to what was expected. Healthcare facilities and organizations stand to lose millions of dollars in federal healthcare reimbursement when outcomes are lower than established thresholds. This can impact entire communities - facilities that lose money, can’t stay open.

Outcomes relate to:

Physiological measurements Psychological status Functional ability Knowledge of self-care Symptom relief Satisfaction with care Performance of daily living activities (ADL's)

Safety outcomes should be patient oriented, realistic, measurable or observable, clear/concise, timed for expectation of completion and involve the patient and their significant others when appropriate. Likewise, the interventions taken while providing care to the patient should be specified in the chart so that a relationship to the outcome can be identified. For example:

Two patients the same age, Mrs. Wilson and Mrs. Craft, have a bronchoscopy with biopsy for the same condition, on the same day, by the same surgeon. Both biopsies are benign. Mrs. Wilson is discharged in three days and experiences a full recovery. Two weeks later she drives herself to the hospital, bringing a box of candy to the nursing station as a “thank you”. Mrs. Craft is discharged in seven days, returns to the hospital in three days with pneumonia and dies. What happened? Why was the outcome different? The medical records are evaluated for clues that may have contributed to the outcome differences. This is where the comprehensiveness of your documentation becomes important, to clarify the nursing care that was provided – hopefully, thorough documentation will support that everything from a nursing assessment and care delivery standpoint evidence appropriate care was provided.

Documentation and thorough initial assessment are especially important and have new major financial implications beyond malpractice risk. Patients must be carefully assessed for problems upon admission that may otherwise subsequently occur during their stay such as pressure ulcers and urinary tract infection when an indwelling catheter is present. In 2008,

reimbursement for these problems disappeared when they are considered nosocomial – that is occurring during hospitalization - will not result in any additional payment to the hospital. The same care must be provided and the same treatments administered, it’s just that the facility will lose money. Especially problematic when they were not properly /documented on admission and could have been reimbursed for.

The Nurse as a Teacher

You are almost constantly providing patient education. Take credit for your efforts in attempting to correct the knowledge deficits of patients. Include the patient's response: Mr. Smith verbalized understanding of urinary catheter care and stated “I will empty my drainage bag frequently to reduce the risk of infection”. Provide evidence that the patient really can put his new knowledge to work by watching him do it and then you chart: “Return demonstration observed, patient emptied drainage bag without difficulty”.

Do not assume because a patient has had a disease or a problem for a long time that they are caring for themselves appropriately and do not require teaching. The actual reason a patient may be ill is not from noncompliance but as a result of compliance to an older standard of care or procedure or belief which has been found to be not appropriate. An example would be the mother who bundles up the baby with a fever to stop him from shivering.

Late Entries/Errors

Late entries happen. In a small nursing home without an EMR you're halfway through your opening assessment for the 7-3 shift on Mr. Sears in the first bed when you realize that you've been documenting on the second bed patient, Mr. Roebuck's medical record! Now what? Do you...

1. Tear up the note, get a fresh blank one and start over (asking the 11-7 nurse to re-chart her findings when she returns tonight)?

2. Head for the desk and frantically search for the correction fluid?3. Cross through all the data you entered with a thick dark marker?4. Whip out that handy ink-eraser?

NONE of the above choices are acceptable. All of those actions are inappropriate and could be considered tampering with a medical record. At many facilities (be sure to check what is required where you work), the appropriate method for denoting a chart entry mistakenly entered is to cross through it with a single black line and write error and initial it.

Studies have shown that writing error above the entry may cast a negative impression of the nurse on the jury. Research has indicated that indicating “mistaken chart entry” may be a more acceptable term. You may want to discuss this with the risk manager at your

facility/organization – but regardless, be sure to adhere to the current policy at the time you are documenting.

Late entries should be made as soon as the discovery of omitting the data is discovered. This is a gray area and may require speaking with the risk manager. A late entry at 7:30am the next day you care for the patient to describe the dressing change you did at 6:30pm yesterday would be appropriate. Entering a note to document safety instruction and use of the call bell to request assistance in getting out of bed after the patient falls on the floor and fractures a hip two weeks after you last cared for them is not appropriate.

General rule of thumb if it seems like you are trying to cover something up by making a late entry:

1. Chances are you probably are, and2. A good lawyer will scrutinize your entry and the motive behind its creation, carefully

trying to convince the jury that not only are you an incompetent nurse, but you don't document truthfully!

A note about ink for portions of the chart that are not electronic... the original medical record may be evaluated by handwriting experts in a lawsuit. Ink from pens can be identified by the year of production and can be differentiated from the ink used or writing made at some other time. Revising notes, adding entries or creating a new note can be devastating to a lawsuit defense. These actions can also jeopardize your professional nursing license!

A Few Words About Handwriting

Remember, having legible penmanship is really crucial to two major safety issues - the safety of the patients you care for and the safety of your own professional future.

Unclear penmanship has resulted in medical errors, medication errors, and death Unnecessary time is spent deciphering illegible penmanship Treatment records are irrelevant if they cannot be understood - how you write is as

important as what you write Hurried documentation impacts penmanship clarity, information accuracy and often

results in greater rates of omitted data Illegible penmanship results in ineffective communication between health care

providers and hinders coordination of a comprehensive plan of care Regulating agencies, such as the Joint Commission mandate legible handwriting in

medical records, particularly because of the high number of medical errors associated with illegible handwriting. Non-compliance can lead to unfavorable findings when discovered by surveyors. It’s a sure bet that nurses with illegible handwriting that result in unfavorable survey recommendations will most certainly not have a favorable status in the eyes of nursing or facility/organizational administration!

Poor penmanship may result from a wide spectrum of causes ranging from hurried work performance and laziness at the least to physical or psychological problems at the worst

Poor penmanship is often viewed as a potential indicator of substance abuse and psychological disorders including obsessive-compulsive disorder. These serious relationships stem from graphology, the science of handwriting evaluation, supported by the belief that handwriting reveals personality traits and disorders.

Poor penmanship may also be indicative of underlying or undiagnosed disease processes including Huntington’s disease, essential tremors, Parkinson’s, and Alzheimer’s disease.

Define the Scope of The Problem

Up to 25% of medication errors are related to illegible handwriting The Institute of Medicine has reported that medical mistakes overall, including those

stemming from illegible documentation, may cause up to 98,000 deaths annually (12) Medication errors are ranked as the eighth leading cause of death in the United States

(12) Nurses often write fast, yet speed contributes to illegibility of medication orders and

subsequent errors.

My Handwriting Is Sloppy…What Can I Do?

Print!! Or at least employ a combination of script and print, using print for easily misunderstood or often illegible words or medications or orders. Forget what your third-grade teacher told you (that cursive writing is grown-up writing) adults really do print and if the quality of your script writing is less than excellent this is a viable option to improve your written communication efforts. Also dispel the myth that script writing is faster than printing - research has shown this to be untrue.

Slow down when writing - the additional seconds spent can save a life or potential lifetime of misery!

Recognize that numbers MUST be clearly written and that zeros can make a big difference when improperly used – they typically result in ten-fold dosage errors.

Omit trailing zeros after decimal points:

2 or 2. NOT 2.0 - the decimal point can be over-looked and misread as 20

Use leading zeros before fractional numbers:

0.2 NOT .2 - the decimal point can be over-looked and misread as 2

Avoid decimals when possible, use 500 mg instead of 0.5 g

Alternatives

Promote legible handwriting early on in practice or when mentoring others. Refrain from demonstrating a bad attitude when you are asked to clarify your writing or worse yet criticize the ability of others to decipher your writing. Instead, recognize the request for clarification as a twofold blessing:

Others are trying to prevent a medical/medication error from happening You are being given objective feedback that there is a problem with your penmanship -

an opportunity to improve before disaster strikes

Improving penmanship quality is an important step to take in reducing medical and medication errors, enhancing therapeutic professional communication, reducing nonproductive time deciphering written communication, reducing legal liability, improving your professional image among staff members, patients, family members, and, heaven forbid the time ever come, defense attorneys and jurors.

Never Do These Things

Leave blank spaces for others to catch-up or document later. Never leave blank spaces on forms or blank lines on the EMR - use n/a or cross through the space when appropriate (as dictated by your facility or organizational policy)

Destroy or change any part of the medical record after it has been created. White Out® is an obvious forbidden item. Hospital policy should be observed when inadvertent documenting has occurred. (Actually, tampering with the medical record or an appearance of attempting to cover-up a mistake is a sure-fire way of fueling a lawsuit against the hospital).

Never document in advance. Routine care is timed and documented on graphic sheets that are not very specific…how many times are first morning vital signs done between 6-8am by the nursing assistants (to save the busy day shift time) and documented on the 8am spot? How would you explain the vital signs documented for 8am on the graphic sheet when the patient coded and died at 7:50 am?

Never chart for others. Document only care you provide or supervise directly. Never document the observations of someone else unless stated in a quote and identify

the speaker. Example: “patient fell on floor” is not a correct way to chart your findings when you walk into a room and a patient is on the floor. “Patient found on floor next to bed” or patient's wife, Mrs. Smith states “my husband fell on the floor” should be documented to reflect the discovery of the event.

Never document in a fashion which could be determined as a negative assault on the patient's character. Example: you know the patient in your ER is drunk and obnoxious. You cannot document this (you can hope the nice traffic officer shows up with a warrant for his arrest and a lab tube for a blood alcohol specimen). What you can document is

that “The patient refuses to have x-rays performed, refused assessment, was observed to have a very unsteady gait while ambulating to the waiting room and urinated in the suggestion box on the admitting secretaries desk.” If the same patient is verbally abusive, it is appropriate to document exactly what he said as a quote. Be sure to include notification of the appropriate supervisor(s) etc. and any measures you are able to take to protect the patient from his own stupidity. This will be especially important when you find out the next day that this patient was killed in traffic after running out of the hospital and, oh yes, his father is one of the states’ top malpractice attorneys.

Computers to The Rescue

As mentioned earlier, an overwhelming majority of institutions and organizations have implemented electronic medical records and a national goal in the United States was the full implementation of electronic medical records by the year 2014, however this has not yet been achieved in all institutions. While many acute care facilities are striving to meet the goal because there is a financial penalty for non-compliance, smaller facilities, non-acute settings, and other health care sites where nurses work may still continue to rely on traditional pen and paper documentation.

Nurses both welcome and despise electronic medical records for a multitude of reasons. To some extent, computer fields can be created to prompt nurses to address important areas and more thoroughly document they care they have given, but they are not the answer to achieving the perfect documentation. While highly-sophisticated programs can prompt nurses to document critical elements before logging off a screen, they cannot often control the quality of information contained within the medical record via text or typing fields. Remember- the garbage in…garbage out rule applies. It just looks a bit neater because the sloppy handwriting is gone.

When electronic documentation is implemented, there is a learning curve to conquer and this is especially difficult for the older nurses who were not brought up in the computer era. The selection or ergonomic equipment and design of documentation workstations are very important. Some nurses view computerized documentation as a timesaver that improves their performance and others view it as a distraction that can improve documentation at the expense of taking time away from direct patient care (13).

Case Study

Nurse Jen is working on a med/surg floor. She is taking care of Mary. Mary is in with a Stage IV wound on her foot. She has been diabetic for many years and her A1C is 13. Mary does not take her condition seriously and frequently refuses care. Nurse Jen tries to engage Mary in her care every chance she gets. Nurse Jen has been caring for Mary for about a week and has been off the last two evenings. Saturday was very busy and Mary refused to let Nurse Jen change her

dressing on her wound at 8:30 pm. Nurse Jen then had a patient go into cardiac arrest and a new admission. The next night Nurse Jen works on another floor. The next time she is on her regular floor, she finds out that Mary is scheduled to have her foot amputated. Nurse Jen starts looking at the electronic medical record to see what is going on with Mary. She notices that she did not chart Mary’s refusal of the dressing change or the fact that she went back later to attempt to change the dressing again. She also notices that the other nurse that took care of Mary did not change the dressing either.

Review Questions1) Nurse Jen needs to complete an incident report after finding the dressing on Mary’s

wound has not been changed in three days. Where should she chart this in Mary’s medical record?

a) Chart under the dressing change section that an incident report was completedb) Do not chart in the medical record that an incident report was createdc) Write a progress note about the incident reportd) Chart that the incident report was completed in the medication section since

Mary has an order for pain medicine as needed prior to dressing change

2) Nurse Jen wants to go back and document the events from the evening. How would she go about this?

a) Go back to that day and add her entriesb) Go back to the charting for the other nurses and add their entriesc) Leave it off and don’t worry about itd) Do a late entry-be sure to write the current date and the date that the event

happened. Also be sure to add initials/signature

3) Mary’s family sues the hospital. All of the nurses involved in Mary’s care have to testify and their documentation is displayed for all to see. Nurse Jen is the only nurse that went back and completed a late entry. The jury will most likely________.

a) Think that Nurse Jen did everything she could for Maryb) Think that the other nurses did not provide adequate carec) Think that it is Mary’s fault for not taking her diabetes seriouslyd) Find that all the nurses are at fault. There is missing documentation and late

documentation showing a pattern of issues in Mary’s care

Review Questions Explained1) Nurse Jen needs to complete an incident report after finding the dressing on Mary’s

wound has not been changed in three days. Where should she chart this in Mary’s medical record?

a) Incorrect. Incident report completed should not be documented in the chart under the dressing change section that an incident report was completed

b) Correct. Do not chart in the medical record that an incident report was createdc) Incorrect. Do not document that an incident report was completed in a progress

noted) Incorrect. Do not chart that the incident report was completed in the medication

section since Mary has an order for pain medicine as needed prior to dressing change

2) Nurse Jen wants to go back and document the events from the evening. How would she go about this?

a) Incorrect. It is unethical and improper to go back to that day and add her entriesb) Incorrect. It is unethical and illegal to go back to the charting for the other nurses

and add their entriesc) Incorrect. You should not leave it off and don’t worry about it. Care you have

given or not given should be documented.d) Correct. This is the only proper way to complete documentation. Do a late entry-

be sure to write the current date and the date that the event happened. Also be sure to add initials/signature

3) Mary’s family sues the hospital. All of the nurses involved in Mary’s care have to testify and their documentation is displayed for all to see. Nurse Jen is the only nurse that went back and completed a late entry. The jury will most likely________.

a) Incorrect. Think that Nurse Jen did everything she could for Maryb) Incorrect. This answer is not the most correct. Think that the other nurses did

not provide adequate carec) Incorrect. Think that it is Mary’s fault for not taking her diabetes seriouslyd) Correct. Find that all the nurses are at fault. There is missing documentation and

late documentation showing a pattern of issues in Mary’s care

Putting It All Together

Document as you go Document the facts-support them with clear descriptive evidence Include quotations when they are appropriate Leave opinions, biases and blame out of the medical record Document neatly- imagine your own writing on a 3'x5' poster in a courtroom. Would

you be ashamed? Sloppy documentation = sloppy care in the eyes of a jury Negative patient outcomes are inevitable. Clear, concise, thorough documenting can

serve as evidence that you provided all the nursing care possible to prevent the negative outcome

All interventions or teaching encounters must have a corresponding patient response documented

The admitting assessment is probably the most important documentation you will do to establish a basis for comparison for the care you give and the patient's progress

NEVER indicate in the medical record that an incident or occurrence report was completed. Do clearly document your findings and the interventions taken to care for and protect the patient

When assessing subjective patient data. Make use of “pain scales ...from 1-10” etc. assign a measurable quantity instead of noting vague descriptions such as some relief or poor relief. Measure in terms of millimeters and centimeters not “dime sized” or “plum-sized” area

Be sure your documentation reflects compliance with hospital policy and procedure, physician's orders and appropriate use of the chain-of command when required

Stick with approved abbreviations and avoid “do not use” or dangerous and often misinterpreted ones

Evaluate your handwriting – if it is sloppy –PRINT! Be sure verbal or phone orders you write are complete, appropriate and clearly written

– it is a good idea (and often required at some facilities) to read back the orders before completing your call to assure clarity – then document that you did so

References1. Butler, K. A., & Lostritto, M. D. (2015). Malpractice 101: Strategies for Defending

Your Practice. Journal of Radiology Nursing, 34(1), 13-24.2. Ballard DC. The Nurse and Documentation. Chapter. In: Ballard D, Grant PD, Eds.

Law for nurse leaders, 2nd ed.2017. New York: Springer.3. Grant PD. Nursing malpractice/ negligence and liability. Chapter. In: Ballard D,

Grant PD, Eds. Law for nurse leaders, 2nd ed.2017. New York: Springer.4. Holland K. Cultural awareness in nursing and health care, 3rd Ed. 2017. Boca

Raton, FL: CRC Press.

5. Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care. (2021, April 01). Retrieved May 01, 2021, from https://www.sciencedirect.com/science/article/abs/pii/S1553725021000696

6. Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review. CMAJ Open. 2017;5(2):E345-E353. doi:10.9778/cmajo.20170023.

7. Kreckman J,Wasey W, Wise S, et al. Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care

team. BMJ Open Qual. 2018; 7(2): e000281. Published online 2018 Apr 20. doi: 10.1136/bmjoq-2017-000281

8. Tong M; Oh HY, Thomas J, et al. Nursing Home Medication Reconciliation: A Quality Improvement Initiative. Journal of Gerontological Nursing. 2017;43(4):9-14. https://doi.org/10.3928/00989134-20170313-04

9. Hias J, Van der Linden L, Spriet I,et al. Predictors for unintentional medication reconciliation discrepancies in preadmission medication: a systematic review.European Journal of Clinical Pharmacology. 2017;73(11):1355–1377.

10. Raper SE, Rose D, Nepps ME, et al. Taking the Initiative: Risk-Reduction Strategies and Decreased Malpractice Costs. Journal of the American College of Surgeons. Volume 225 , Issue 5 , 612 – 621.

11. Kohn LT, Corrigan JM, Donaldson X, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

12. Raddaha AHA, Obeidat A, Awaisi HA, Hayundi J. Opinions, perceptions and attitudes toward an electronic health record system among practicing nurses. Journal of Nursing Education and Practice. 2018;8(3):12-22. doi: 10.5430/jnep.v8n3p12

Course Exam

1. It would be prudent to always document an IV site assessment before and after administering which of the following medications:

a. furosemideb. famotidinec. phenytoin d. cefazolin

2. A negative feature of flow sheets or flow grids/charts in an electronic medical record is:a. they are quick to fill outb. they decrease the duplication of datac. they are standardized and impersonal d. they are structured and organized

3. You are documenting a patient’s medication history. To be thorough, it is MOST IMPORTANT to include:

a. medication allergiesb. name, dose, frequency, and time of last dose of each medication takenc. names of non-prescription meds including herbal/health store & 'home'

remediesd. All of the components are required for a thorough medication history

documentation

4. You want to assess a patient’s pain using the P-Q-R-S-T mnemonic. These letters stand for:

a. Pain Level / Quality / Region / Severity / Treatmentb. Provokes / Quality / Recurrence / Severity / Treatmentc. Provokes / Quality / Region or Radiation / Strength / Treatments usedd. Provokes / Quality / Region or Radiation / Severity / Time

5. You are administering an IM injection to a patient for nausea, the BEST way to identify the site of administration is to document delivery in the:

a. right armb. right deltoid c. left buttockd. right upper leg

6. Which of the following statements is TRUE?

a. Your nursing care documented must reflect consistency with a community standard of care

b. Documenting comments which place the blame on others for an error is a protective legal defense for the nurse

c. Printing is a sign of immaturity and should be discouragedd. A negative patient outcome usually indicates poor nursing care

7. With respect to malpractice, you know that most cases center around:a. simple acts and basic care b. negligencec. medication errorsd. wrong site procedures

8. You are working in a nursing home that still utilizes paper documentation. Six lines into your documentation you realize that you are documenting the assessment for your patient on the wrong chart. You will:

a. Head for the desk and frantically search for the correction fluidb. Cross through all the data you entered with a thick dark markerc. Cross through the information you charted with a single black line and write

“error d. Whip out that handy ink-eraser and remove the entry

9. Your patient is prescribed oral Zofran for nausea. She has difficulty swallowing and did not want to take the pills but was very nauseous. Your best documentation entry would be:

a. “Patient refused oral Zofran pills”b. “Patient refused oral Zofran pills despite education”c. “Patient refused oral Zofran pills despite having nausea – demonstrating

negative attitude with all care”d. “Pt refused oral Zofran pills – stated she cannot swallow pills. Call to Dr. Brown

to notify and request liquid or IV antiemetic alternative”

10. Medication reconciliation:a. must be conducted and documented on admission and at dischargeb. is recommended for patients with chronic diseases such as diabetes and

hypertensionc. May be completed pharmacy staff – it compares physician orders to the patient’s

medicines at homed. All of the above are true about medication reconciliation

11. Your patient had hip surgery 2 days ago. He complains of leg pain. Which of the following statements is TRUE?

a. You will question the patient because you are concerned about substance abuse and addiction to the pain medication

b. You know the source of the pain is surgical and you will administer the pain medication as ordered

c. You will want to carefully assess & document the pain to differentiate post-op pain from that potentially associated with a deep vein thrombosis (DVT)

d. Pain medication should be administered quickly to “medicate away” the unpleasant symptom

12. You find a patient on the floor and are asked to complete an incident report. On the incident report, you will want to:

a. Document who was responsible for watching the patient so that they can be re-educated on patient safety

b. Identify if this is the first time this problem has happened or if the patient has fallen multiple times before

c. only include what you directly observed d. identify how to reduce patient falls in the future

13. Effective documentation:a. will make a lawsuit impossibleb. can take the place of a verbal reportc. does not include patient quotes as they are too subjectived. communicates data between various care givers regarding patient status and

outcomes, serves as a permanent legal record of care given, and communicates the critical thinking process ability of care givers

14. Which of the following statements is TRUE?a. Including an incident report in the chart does little to protect hospitals / nurses

in the event of a lawsuitb. When assessing the history of a problem or injury it is best to assume that the

accident caused the problemc. Thorough assessment of a complaint (such as pain) may actually change the

intervention or medication choice d. Language/educational level/developmental delays are acceptable reasons for

not assessing and gathering history and information

15. Which of the following statements is TRUE?a. It is not necessary to document small or routine safety instructions

b. A complete chart entry for a medication, procedure, or intervention always includes mention of the patient’s response

c. It is acceptable to 'leave space' on the medical record for other nurses to complete their documentation when it is busy on the nursing unit

d. When an unforeseen or negative situation occurs, the patient's medical record must reflect that you completed an incident report

16. Documenting “defensively” means:a. Identifying who is to blame when an error occursb. Having patients admit when they do not comply in case a bad outcome occursc. Carefully covering all the required elements necessary for providing the

expected “standard of care” in the community d. Assuming that there will be a bad outcome and protecting yourself by

documenting as little as possible

17. _______________ dictates that privacy measures be implemented and followed by every person who has access to private medical information.

a. The Joint Commission (TJC)b. The Agency for Healthcare Administration (ACHA)c. The Health Information Portability & Accountability Act of 1996 (HIPAA) d. The Emergency Medicine Treatment and Labor Act (EMTALA)

18. The #1 witness in a malpractice suit is:a. the physicianb. the nursec. the patientd. the medical record

19. You are caring for Albert, a psychiatric patient. With respect to his history and physical assessment:

a. Most of what he says will be irrelevantb. You must not ignore or downplay his symptoms c. Your observations are more important than what the patient says or complains

ofd. You can’t assume the patient is telling the truth

20. Which of the following statements is TRUE?a. It is not necessary to document small or routine safety instructionsb. A complete chart entry for a medication, procedure, or intervention always

includes mention of the patient’s response

c. It is acceptable to 'leave space' on the medical record for other nurses to complete their documentation when it is busy on the nursing unit

d. When an unforeseen or negative situation occurs, the patient's medical record must reflect that you completed an incident report

21. Which nurse is MOST LIKELY to be sued?a. A nurse who administers a medication to a patient with no known allergies and

the patient has an allergic reactionb. A nurse who finds a confused patient on the floorc. A nurse who administers medications 15 minutes lated. A nurse who does not question a physician order for a high dose of a medication

and the patient has an adverse reaction because of the dosing error

22. Which of the following medication orders is expressed in the SAFEST way possible?a. 2.0 mg Morphine Sulfate IV Q4 hours PRN painb. 0.5 G Acetaminophen Q 4 hours PO PRN pain or headachec. 10 units Lantus SC at bedtime d. .5 mg Dilaudid Q2 hours IV PRN pain

23. Which of the following statements is TRUE?a. Your patient speaks Spanish, you do not, yet interpreters are available. It is

expected that the documentation on this chart will not be as complete because of the language barrier - this will be an acceptable malpractice defense excuse

b. When a nursing intervention is provided, the patient's response to the intervention must also be documented

c. “Triaging” only takes place in the emergency departmentd. If you follow a nurse who charted incompletely, you may complete her

documentation with the information you received in report so that the chart does not have information gaps

24. Which statement is TRUE?a. Good outcomes provide evidence of quality nursing careb. Not documented….not done c. Bad outcomes provide evidence of poor-quality nursing cared. The medical record does not matter in a court of law

25. Problems that must be identified and documented upon admission to reduce the risk for malpractice suits and undesirable financial repercussions include:

a. presence of a pressure ulcer or break in the skin integrityb. presence or signs of a urinary tract infection on admissionc. religious preference that will impact acceptable care and treatments

d. All of the problems identified above are important to assess for and document

26. Which of the following is not a positive aspect of documenting in a flow sheet?a. Quick to completeb. Prevents duplication of datac. They are personal for each patientd. They are structured and organized

27. Which of the following is acceptable to document about a patient?a. Patient presents to ER and is being obnoxious.b. The patient smells bad and has probably not had a shower in a week.c. The patient urinated in the water pitcher. d. The patient is drunk.

28. Prior to the implementation of electronic medical record, illegible handwriting was thought to be responsible for what percentage of medication errors?

a. 25%b. 10%c. 50%d. 15%

29. Which of the following is not a purpose of the nursing documentation?a. Provider’s ordersb. Wound characteristicsc. Vital signsd. Care given

30. What does the “quality” mean in PQRST?a. How did the action work?b. What does it feel like? c. How was care given?d. When did it start?