By Paola DiNatale
Healthcare providers understand too well that the patient’s clinical record documentation is based on the clinical situation, however too often we get trapped in the mindset of ‘when it’s too much or too little reporting’. Long passed are the good ole days when the clinical record documentation meant ensuring that the correct color ink was used to document and recognize the shift worked during a 24-hour period (Blue/Black Ink-Day shift, Green Ink-Evening shift and Red Ink-Night shift). Well, time has since moved on, and the focus of the clinical record documentation shifted from what color ink pen to use, to documenting services rendered associated with providing quality of care, promoting quality of life, identifying level of care need for reimbursement purposes, and most importantly, mitigating liability risk.
Origins of Nursing Documentation
Looking back through nursing history, we can credit Florence Nightingale as the first nurse theorist and founder of nursing documentation. In Notes on Nursing, she stressed the importance of gathering patient information in a clear, concise, and organized manner with a strong focus on consistency (known as the three C’s). Nightingale’s theories on nursing gained acceptance, as she raised the status of nursing education, and clinicians began to accept her notion about the value of nurse’s perceptions and observations. As her hypothesis evolved, so did the theory that the clinical/medical record should contain a road map of actual and potential patient driven care, identifying problems and appropriate interventions, while also being easy to read and accessible to all members of the health care team. The patient’s clinical record documentation has many purposes, but essentially it assists all caregivers in coordinating patient treatment, ensuring accurate reimbursement, and guarding against liability issues.
In Documentation, Less Is Not More
As technological advances paved the way for the electronic health record (EHR/EMR) and providers’ ability to streamline the documentation process through customizable templates, it gave rise to a mindset that perhaps less documentation is more. Regardless of what clinical record format or software platform is in place, lack of patient care documentation has a potential impact to the REITs who own and operate income producing real estate in a range of property sectors. For example, if a Skilled Nursing Facility (SNF) has an active risk profile including increased claims activity relevant to allegations of malpractice, and the plaintiff’s clinical records are lacking pertinent documented details to support a defense, then the SNF may be at jeopardy with trickled down effects for meeting its financial obligations to the REIT.
In the decades since the establishment of REITs, scholarly articles and abstracts have been published on the topics of institutional shareholder investments; although, opinions differ on the importance of identifying litigation risk factors relative to tenant and property risk. However, from both the SNFs and the REITs perspective, the focus should be geared toward decreasing future risk and balancing it with meeting clinical record documentation standards.
Clinical Record Documentation Strategy
Well known evidence-based documentation strategies focus on a clear and complete plan of care that:
- legibly communicates pertinent patient information,
- supports a proficient and competent level of care, and
- creates a strong defense against potential allegations of malpractice by aligning patient and provider expectations.
Documentation Is Your Defense
“Documentation is your defense”- words that should permanently ring in our ears. Without documentation to support the care given, it is difficult to help defend a case, thus making it easier for plaintiff to prevail. The most powerful defense in the event of a claim or lawsuit is to document the basis for the clinical decision making. Broadly speaking, documentation addresses the preparation and maintenance of clinical records that describes a patient’s care with a focus on attention to details. Let’s face it – it’s all about the details, regardless of the color ink being used!
Paola DiNatale, MSN, RN, NHA
Senior Healthcare Specialist