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documentation arent tied to any specific charting sys-tem. Rather, they are general principles that can beapplied to any system an organization adopts. Someclinical settings, for example, use a paper formbased,narrative style of charting; others use setting- or unit-specific flow sheets; still others use charting by excep-tion, recording only exceptions to normal findings.Regardless of the system used, the purpose of docu-mentation, from a legal perspective, is always to accu-rately and completely record the care given to patients,as well as their response to that care. (For more, seeCharting the Course, page 59, and The Purpose ofMedical Record Documentation, page 60.)

HARTZELL V. CITY OF WARREN, ET AL.In civil litigation in which there is alleged negligenceor nursing malpractice, documentation in the med-ical record can exonerate accused nurses regardlessof their practice setting. Such was the case inHartzell v. City of Warren, et al., in which a nursewho worked at a correctional facility was named asa defendant.5 The case was decided by the MichiganCourt of Appeals in May 2005.

In this case, Debra Cisco, RN, was one of a num-ber of defendants who was accused of providinggrossly negligent, life-ending nursing care to RobbieHartzell. Ciscos documentation of her interactionwith Hartzell, as well as her deposition testimony, ledthe appellate court to conclude that she was notgrossly negligent and did not commit malpractice.

Cisco evaluated Hartzell at 9:30 pm on July 27,1998, at the Macomb County Jail in Mt. Clemens,Michigan. She measured his blood pressure anddetermined that it was within normal and accept-able limits at 132/94 mmHg. She noted thatHartzell said that, after surgical repair of a cerebralaneurysm and intracerebral hemorrhage a monthbefore, hed begun taking 0.2 mg Catapres (cloni-dine) by mouth twice daily to manage hypertension.He said that he had no other medical problems thatrequired immediate attention. Because Hartzell hadnot yet been examined by a physician, Ciscoarranged for that to occur the following day.

The next day, July 28, at 12:55 pm, Ernest Bedia,MD, examined Hartzell and determined that hisblood pressure was 180/108 mmHg. The physician

Overview: This article discusses principlesthat inform all good methods of charting andexamines an actual court case to illustrate howadequate documentation can protect nursesagainst allegations of negligence and malprac-tice. Also discussed are the importance of pre-serving the medical record and mistakescommonly made in charting that leave nursesvulnerable to lawsuits.

In 2003 the American Nurses Association(ANA) introduced its Principles for Docu-mentation,1 based on the ANAs Code of Ethicsfor Nurses with Interpretive Statements andNursing: Scope and Standards of Practice.2, 3

These principles suggest that documentation systemsmust be designed in consultation with nursing staff so

that the concerns of nurses are addressed beforethe documentation system is implemented.

promote a record once, read many timesapproach to avoid duplicate recording by differ-ent providers.

use ANA-recognized data sets (for example, theANAs National Database of Nursing QualityIndicators, developed in collaboration with theUniversity of Kansas School of Nursing, whichcompiles data on nursing-sensitive indicators,including patient falls and pressure ulcers, staffmix, nursing hours per patient day, job satisfac-tion, and nurse education and certification4).

be readily accessible by nurses and support dataanalysis.

encourage nurses to critically evaluate the systemof documentation and patient outcomes.Its important to understand that these standards of

Documentation, Part 1: Principles for Self-ProtectionPreserve the medical recordand defend yourself.

Kammie Monarch is a nurse attorney and chief operating offi-cer of Sigma Theta Tau International, the Honor Society ofNursing. Contact author: kammie@stti.iupui.edu.

ajn@wolterskluwer.com AJN t July 2007 t Vol. 107, No. 7 59

ordered blood pressure monitoring twice weekly;0.2 mg Catapres and Ecotrin (aspirin) once daily.

The medical record indicated that, according tothe physicians orders, Catapres was given at 3:15 pmon July 28. The initials of another nurse, JanieKushniruk, were on the patients chart, indicatingthat she had administered the medication, butKushniruk testified that she had not given the med-ication and had not given anyone permission tosign her initials on the chart. Hartzell was foundunconscious with a blood pressure of 280/200mmHg. He died two days later at a nearby hospi-tal. In the lawsuit, representatives of Hartzellsestate alleged, among other things, that Hartzellhad been denied proper medical care, includingmedication, an omission that caused his death.

After reviewing the evidence, the appellate courtconcluded that neither Bedia nor Cisco was deliber-ately indifferent to Hartzells serious medical needs.To support this conclusion, the court pointed to thedocumentation submitted by Cisco, concluding thatthere was no indication that Cisco, the physician, oranyone else intentionally denied or unreasonablydelayed treatment. Accordingly, the Michigan Courtof Appeals precluded Hartzells estate from pursuingits claims against Cisco and Bedia.

This case demonstrates that any interaction with apatient can result in litigation. Therefore, on even thebusiest days, nurses need to complete documentationcarefully and in accordance with the standards of care(for more, see Documentation, Part II: The BestEvidence of Care, page 61). As long as the care pro-vided is consistent with the standards of care, nurseswho follow documentation procedures as describedhere will be in a good position to defend themselvesif theyre ever accused of failing to6

assess, analyze, and act according to the level ofcare the patient needs.

ascertain the patients wishes concerning self-determination.

make an appropriate nursing diagnosis, identifythe patients needs, and implement an appropri-ate plan of care.

communicate promptly any clinically significantchanges or trends in the patients condition orresponses to interventions.

take appropriate action. protect patient privacy. act as a patient advocate.

PRESERVING THE MEDICAL RECORDRegardless of the practice setting, nurses must pre-serve the integrity of the medical record in the fol-lowing ways.

Accurate and complete patient information mustbe entered on all paper and electronic docu-ments.

Other diagnostic records and reports, includingbut not limited to electrocardiogram, fetal mon-itor, and other diagnostic recording strips; con-sultation, laboratory, radiology, and other testreports; procedure results; and other forms mustbe properly labeled, sequentially listed or refer-enced, and kept with the medical record.

All unofficial papers, such as a nurses to-do list,must be removed from the patient care area sothey are not included in the medical record.

All documentation practices must be consistentwith the standards associated with the patientpopulation for which care is being provided.This applies to both the schedule according towhich documentation is to be performed and thestylistic conventions and substance of the nota-tions themselves. Any special documentationrequirements for specialty and high-risk settingsmust also be followed.

Abbreviations on the Joint CommissionsOfficial Do Not Use List should not be used(go to www.jointcommission.org/patientsafety/donotuselist). Avoid ambiguous abbreviationssuch as SOB, which can mean either short-ness of breath or side of bed.

Nurses must read medical record entries andassess the patient themselves before cosigninganother clinicians assessment records.

By Kammie Monarch, JD, RN

Charting the CourseA free online video presentation on different charting methods.

Do you have questions about the policies and proce-dures that govern charting in your workplace? Doyou know whatand what notto chart? Do you knowwhy its important to document all of the care you pro-vide to patients factually, accurately, completely, andpromptly?

If youre in doubt about the answers to any of thesequestions, you might benefit by viewing a free, 30-minuteonline video presentation, Charting the Course forNursing: Who Benefits When Charting Is Complete? (go to www.nursingcenter.com/AJNdocumentation). Thevideo program, supported in part by a grant from theNurses Service Organization, explains several methods ofcharting and can help you evaluate the method used atyour workplace.James M. Stubenrauch, senior editor

60 AJN t July 2007 t Vol. 107, No. 7 http://www.nursingcenter.com

Late entries must be made in accordance withacceptable organizational standards.

Interventions delineated in critical pathways,guidelines, policies, procedures, protocols, stan-dards, and care plans must be followed and doc-umented. If a standard recommendation is notfollowed, the reasons for this must be docu-mented.

The patients response to interventions and theclinicians response to a worsening condition orworrisome indicator must be recorded promptly.

Physicians orders must be transcribed and accom-plished as quickly as possible.

Discharge instructions and the patients responseto them must be noted.

Personal, critical, and judgmental opinions con-cerning health care providers, patients, and fam-ily members must not be recorded.

All attempts to contact other health care profes-sionals must be documented, including the timeof the attempt or contact. Do not document anyspeculation about why another provider mightnot have responded promptly.Nurses who use paper medical records must also

write concisely and legibly, using correct spellingand grammar.

use a black ballpoint pen. draw a single line through erroneous entries to

identify them as erroneous. use addendum pages as needed in a manner con-

sistent with organizational standards.

From a legal perspective, documentation-relatedchallenges arise when there is inattention to orinconsistency in recording the date, time, and patients name on each page

of the medical record. only sequential, factual information, even when

deviations occur (such as when a medication orother treatment is given later than ordered).

the time at which the assistance of otherproviders is requested.

admission data and the patients wishes withregard to self-determination, using the patientsverbatim responses when possible.

pain intensity, location, accompanying factors,the interventions performed, and the patientsresponses.

steps taken to follow preadministration proto-cols or policies related to blood, blood products,chemotherapeutic agents, and other high-riskinfusions or medications.

assessment data, the interventions performed,and the patients responses, noting deviationsfrom normal or expected findings and actionstaken in light of those findings.

interactions between the patient and other clini-cians.

steps taken to preserve the patients privacy andto address any related concerns of the patient orfamily, including steps taken through the organi-zations chain of command.

transfer times, modes of transfer, and patient sta-tus during and following transfer.

completed treatments, procedures, and interven-tions, as well as those that have not been com-pleted and the reason they were not completed.

the patients response to medication administra-tion. t

REFERENCES1. American Nurses Association. Principles for documentation.

Silver Spring, MD; 2005 Nov. http://nursingworld.org/staffing/lawsuit/principlesdocumentation.pdf.

2. American Nurses Association. Code of ethics for nurseswith interpretive statements. Washington, DC; 2001. http://nursingworld.org/books/pdescr.cfm?cnum=24#CEN21.

3. American Nurses Association. Nursing: scope and standardsof practice. Washington, DC; 2004. http://nursingworld.org/books/pdescr.cfm?cnum=15#03SSNP.

4. American Nurses Association. National Center for NursingQuality Indicators. NDNQI: National Database of NursingQuality Indicators. Transforming data into quality care. TheAssociation. 2004. http://nursingworld.org/quality/ndnqi.pdf.

5. Hartzell v. City of Warren, et al. No. 252458 (Mich. App.05/10/2005).

6. Monarch K. Nursing and the law: trends and issues.Washington, DC: American Nurses Association; 2002.

The Purpose of Medical RecordDocumentation

Hartzell v. City of Warren, et al. illustrates how themedical record can be a powerful and persuasivemultipurpose document. The medical record is used for

substantiating the health condition, illness, or pre-senting concern of a patient.

communicating among health care professionals. recording the patients response to care. auditing care for quality improvement, third-party pay-

ment, and governmental and regulatory purposes. conducting research. resolving competency, disability, guardianship, and

other legal issues. teaching health care professionals about caring for

patients.