3 Documentation Safeguards from Legal Risk

If a safety event occurs at any point in your patient’s care, the patient health care record, and the details that you documented can ensure that the care you gave is spelled out as you would want it to represent you, should a legal review take place. Yet, there are many barriers perioperative nurses face in efforts to document care as complete, comprehensive, and accurate.

“Unfortunately, documentation is not universal. Each patient and each surgery will be different in some way, which requires extra work for a nurse to navigate the electronic health record and chart this unique patient information,” explains Mary Alice Miner, PhD, RN, CNOR, AORN senior perioperative specialist and lead author of AORN’s Guideline for Patient Information Management.

In addition to these charting nuances, “not all electronic health record systems are efficient or nurse-friendly, which has created ‘documentation burden’ for many nurses, adds Janice Kelly, MS, RN-BC, president of AORN Syntegrity, a perioperative documentation solution. “Clinical documentation burden has had a negative impact on health care and is a big barrier to accurate patient records, which puts nurses at legal risk.” 

Kelly and Miner are part of an AORN working group to improve perioperative nurse documentation. Periop Today asked them how comprehensive documentation can reduce a nurse’s chance for legal risk.

Documentation Safeguards

Miner describes these three nursing interventions that illustrate the value of thorough documentation.

1. Accurately Document Medication Administration

Inaccurate documentation of medication administration can lead to patient harm, extended care, and additional costs that could be linked back to poor documentation, Miner says.

For example, if a nurse does not correctly document a medication given, this could lead to a skipped dose of antibiotic, or an additional dose of potassium that affects the patient’s heart rate. In another example, Miner asks, “what if you don't or incorrectly document that you gave insulin? Will someone else come and give too much insulin or not enough and cause the patient to become hypoglycemic or hyperglycemic?”

2. Document All Positioning Actions and Positioning Injury Risks

Positioning injuries can lead to extended patient care and major additional costs that often lead to health care record review because these injuries are deemed non-reimbursable by CMS [Centers for Medicare & Medicaid Services], Miner stresses.

For example, “say a patient develops postoperative nerve and muscular pain potentially related to poor positioning—did you document that you followed the policy for positioning with the surgical table that was used? Did you clearly document that the patient had some prior nerve pain?”

3. Be Thorough with Pre-charting

Nurses may pre-chart things they assume will take place for a patient that they are assigned to, but actual care may end up differing from pre-charting documentation, which can raise questions about nursing actions when discovered, Miner cautions.

For example, say policy or surgeon preference dictates patient skin antisepsis with chlorhexidine, and then the nurse's patient assessment reveals an ostomy that was documented after the intraoperative nurse's assessment, and the OR nurse must go back and remember to change the skin prep to betadine or whatever the OR team decides is best for this patient. “When intraoperative documentation is audited, they may question why this piece of documentation was changed or not updated by the nurse, especially if there was a discrepancy between the nurse's and surgeon's notes—they will question who was right and why the other was not documented correctly, which could lead to remediation, at a minimum.”

Tips to Avoid Documentation Burden

While Miner and Kelly understand the importance of comprehensive nursing care documentation, they also know how documentation burden can get in the way. “More fields for data collection have been added to perioperative documentation records because of legal, regulatory, quality, or organizational self-imposed reporting needs and this can take extra time to complete,” Kelly explains.

Based on AORN’s work to assess documentation burden, Kelly suggests electronic health care record improvements that nurses can champion, including:

• Creating patient-centered clinical documentation that meets clinical workflows,
• Addressing duplicate documentation,
• Eliminating unnecessary documentation,
• Using only carefully reviewed documentation fields, and
• Collaborating with multiple stakeholders such as quality, risk, and legal experts to review perioperative documentation.

Miner stresses the benefits of an organization having an interdisciplinary team and dedicated perioperative informaticist with the expertise to make electronic health record improvements that won’t burden care providers.