Nurses Service Organization (NSO), in collaboration with CNA, has published our 4th Edition of the NSO/CNA Nurse Liability Claim Report. It includes statistical data and case scenarios from CNA claim files, as well as risk management recommendations designed to help nurses reduce their malpractice exposures and improve patient safety.
You may access the complete report, and additional Risk Control Spotlights here.
This Nurse Spotlight focuses the analysis and risk recommendations regarding one of the most significant topics in the report and for nursing professionals: Healthcare Documentation.
While documenting care represents a critical component of nursing processes and standards, the electronic health record [EHR] has posed a level of complexity for nurses who are often challenged with why, how, what and where to document in a patient’s EHR.
Documentation deficiencies are contributing factors to many nurse professional liability claims, as well as license protection matters. However, in the 4th Edition of the NSO/CNA Nurse Liability Claim Report, failure to document or falsifying documentation closed claims, as an allegation of professional liability, increased in distribution and severity when compared to the 2011 closed claim report and the 2015 closed claim report.
To the right is an example of a professional liability claim asserted against a nurse due to the failure to document.
In the 2011 closed claim report, 0.2 percent ($31,250) of all closed claims were related to inadequate or inappropriate documentation as the primary allegation. This data increased slightly to 0.5 percent ($139,920) in the 2015 closed claim report. Respectively, in the 2020 closed claim report, documentation allegations represent 2.0 percent ($238,761) of all closed claims.
The chart demonstrates the increase in severity of professional liability claims related to documentation allegations. While these professional liability claims occur infrequently in the 2011, 2015 and 2020 closed claim analyses, allegations related to documentation failures can be difficult to defend and often result in a license protection defense matter against the nurse.
The chart displays license protection matters with defense expense payments that involve allegations related to documentation. Documentation as a primary allegation comprises 9.7 percent of all license protection matters in the Nurse Liability Claim Report: 4th Edition. Approximately half of the license protection matters related to documentation involve an allegation of fraudulent or falsified patient care or billing records (4.8 percent).
A nurse’s license is one’s livelihood, and its protection is paramount. A nurse’s practice and behavior is expected to be safe, competent, ethical and in compliance with applicable laws and rules. However, when a complaint is filed, nurses must be equipped with the resources to adequately defend themselves. Being unprepared may represent the difference between a nurse retaining or losing the license to practice, a suspension or fine.
NSO/CNA is often asked about documentation risks and recommendations to minimize those risks. Nurses are certainly aware that there are patient healthcare documenting fundamentals.
The healthcare information record is a legal document that is an essential tool to:
Because complete, accurate and legible healthcare records constitute an essential risk management measure, nurses should maintain proper documentation practices and follow facility policies and procedures governing appropriate and comprehensive records documentation. The facility’s healthcare record documentation policies and procedures should address, at a minimum:
QUESTION 1/7
QUESTION 2/7
The answer is true.
NSO and CNA’s latest Nurse Liability Claim Report found that documentation was cited as a primary allegation in 9.7 percent of all license protection matters.
The answer is true.
NSO and CNA’s latest Nurse Liability Claim Report found that documentation was cited as a primary allegation in 9.7 percent of all license protection matters.
QUESTION 3/7
State Board of Nursing complaint.
QUESTION 4/7
The answer is: Personal opinions about the patient’s lifestyle.
Documentation in the patient healthcare information record should be objective; nurses should avoid documenting their personal opinions that are not relevant to the patient’s care. Additionally, nurses should be aware that patients have a right to access their healthcare information records.
The answer is: Personal opinions about the patient’s lifestyle.
Documentation in the patient healthcare information record should be objective; nurses should avoid documenting their personal opinions that are not relevant to the patient’s care. Additionally, nurses should be aware that patients have a right to access their healthcare information records.
QUESTION 5/7
The answer is: Failure to simplify documentation.
While documentation should be concise, it is also important that documentation is complete. Documentation should accurately reflect the patient care and services provided, the patient’s response to treatment, and communication with other practitioners and the patient related to their care. Nurses should maintain proper documentation practices and follow facility policies and procedures governing appropriate and comprehensive documentation.
The answer is: Failure to simplify documentation.
While documentation should be concise, it is also important that documentation is complete. Documentation should accurately reflect the patient care and services provided, the patient’s response to treatment, and communication with other practitioners and the patient related to their care. Nurses should maintain proper documentation practices and follow facility policies and procedures governing appropriate and comprehensive documentation.
QUESTION 6/7
The answer is: All of the above.
It is advisable for nurses to document each of these steps taken to demonstrate that they acted as their patient’s advocate. Nurses are responsible for obtaining the care and services necessary for the timely treatment of patients under their care, and this responsibility continues to the point of resolution.
The answer is: All of the above.
It is advisable for nurses to document each of these steps taken to demonstrate that they acted as their patient’s advocate. Nurses are responsible for obtaining the care and services necessary for the timely treatment of patients under their care, and this responsibility continues to the point of resolution.
QUESTION 7/7
According to the American Nurses Association (ANA), documentation represents a critical competency of all nursing processes and standards of practice (ANA Nursing Scope and Standards of Practice 3rd Edition, 2015).
The ANA Standards of Practice Competencies include the following criteria for appropriate documentation:
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