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Indian J Palliat Care. 2010 Jan-Apr; 16(1): 815. doi: 10.4103/0973-1075.

63128 Copyright Indian Journal of Palliative Care

PMCID: PMC2936087

How Can We Improve Outcomes for Patients and Families Under Palliative Care? Implementing Clinical Audit for Quality Improvement in Resource Limited Settings Lucy Selman and Richard Harding Kings College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, Denmark Hill, London SE5 9PJ, UK Address for correspondence: Lucy Selman; E-mail: lucy.selman@kcl.ac.uk This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES Abstract Palliative care in India has made enormous advances in providing better care for patients and families living with progressive disease, and many clinical services are well placed to begin quality improvement initiatives, including clinical audit. Clinical audit is recognized globally to be essential in all healthcare, as a way of monitoring and improving quality of care. However, it is not common in developing country settings, including India. Clinical audit is a cyclical activity involving: identification of areas of care in need

of improvement, through data collection and analysis utilizing an appropriate questionnaire; setting measurable quality of care targets in specific areas; designing and implementing service improvement strategies; and then re-evaluating quality of care to assess progress towards meeting the targets. Outcome measurement is an important component of clinical audit that has additional advantages; for example, establishing an evidence base for the effectiveness of services. In resource limited contexts, outcome measurement in clinical audit is particularly important as it enables service development to be evidence-based and ensures resources are allocated effectively. Key success factors in conducting clinical audit are identified (shared ownership, training, managerial support, inclusion of all members of staff and a positive approach). The choice of outcome measurement tool is discussed, including the need for a culturally appropriate and validated measure which is brief and simple enough to incorporate into clinical practice and reflects the holistic nature of palliative care. Support for clinical audit is needed at a national level, and development and validation of an outcome measurement tool in the Indian context is a crucial next step. Keywords: Audit, Outcomes, Quality improvement, Quality of care Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES INTRODUCTION Palliative care in resource-poor settings has made enormous advances in providing better care for patients and families living with progressive disease. Now that innovative, sustainable palliative care facilitates are in place in India, these clinical services are well placed to begin considering how to implement simple ways to strive for quality improvement. Clinical audit* is recognized globally to be essential in all healthcare, enabling quality of care to be monitored and improved. While clinical audit is common within palliative care in the developed world, it is far less common in developing country settings, including India.[1]

In this article we outline some of the reasons why clinical audit is so important in palliative care, and make suggestions for how Indian palliative care services can successfully engage with the audit process. Many of our suggestions come out of experience managing the Encompass study (2006-2008), during which the first clinical audit of palliative care services in sub-Saharan Africa was conducted. Working with principal investigators and local research nurses at four palliative care services in South Africa and one in Uganda, we developed a model for palliative care clinical audit in developing country settings which may be relevant to the Indian setting. Here, we aim to introduce the concept of clinical audit within the palliative care setting, and share some of the lessons learnt during that project. Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES MEASURING QUALITY IN HEALTHCARE The quality of a healthcare system (or organization) relates to how effective that system or organization is in achieving it aims. The quality of an organization can be represented and assessed using a four-part model of structure, process, output and outcome [Figure 1]. Each of the four aspects of quality assessment interact, e.g. good structure increases the likelihood of good process, and good process increases the likelihood of good outcome.[2] Figure 1 Contributors to the quality of a palliative care organization (adapted from[13])

It can be useful to collect and reflect on process and output data, e.g. the time between referral and a patient being seen, or the number of referrals to a service, in order to demonstrate or understand the demand for services and practical issues of meeting that demand. However, while assessing how many home care visits are made on each day, or how many patients are seen in a month may provide useful information about how a service is run, does not tell us anything about patients or family members experience of care (for example, having received home care, did the patients pain improve?). Only assessing outcomes of care can provide this kind of information. The outcomes of care (i.e. (4.) in the model) are therefore of particular relevance in measuring quality, as they measure directly the relevance of care for patients, families and society as a whole. Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES WHAT IS CLINICAL AUDIT? Clinical audit is one way to measure quality in healthcare. It can be defined as the systematic critical analysis of the quality of clinical care including procedures used for diagnosis and treatment, the use of resources and resulting outcome and quality of life.*3] In other words, clinical audit means a) looking at how well we currently perform something (e.g. pain management or psychological support), b) setting a target for how well we want to do it, c) deciding how we will make the improvement, d) putting this in place, and e) measuring again to see if we have achieved the target (see Box 1 for more details). Clinical audit is a cyclical activity, although this is often misunderstood: evaluation on its own is not audit, as the

data collected are not used being used to inform changes in service provision which are implemented and evaluated. As Stephen Connor has said, Quality assessment must be tied to quality improvement.*4] For service providers, this could mean conducting a clinical audit every year to make sure the service is always working to improve the care that is delivered. Clinical audit thusbecomes a process of continuous improvement in the quality of care provided by a service, embedded within routine clinical practice and helping to bring about change for the better in terms of patient and family care. Because of its cyclical nature and the dynamism it brings to a healthcare organization, clinical audit has been described as its vital signs or pulse, evidence that the organization is living rather than stagnating.[5] Box 1 Steps in clinical audit

Importantly, clinical audit is not a process of comparing one service with another and finding one or the other to be lacking in some way. Services will have different aims and philosophies, and, as Stjernswald says, You should not compare chocolate with mango.*6] Clinical audit is ultimately about service providers being aware of the quality of their own services care, including areas for potential improvement, and putting steps in place accordingly. The targets for improvement that services set themselves should reflect their stated aims as well as the areas of care currently requiring extra attention. Only when services are sufficiently similar in terms of their aims and the population cared for is comparison meaningful. In this instance, collecting data for audit does enable the effects of implementing different service models to be better understood. However, actual services will always be more complex than the service models they utilize, and should be considered in the context of the specific characteristics of the communities they serve. Clinical audit should not therefore be seen as a threat, but rather as a facilitator that enables more accurate reflection on service provision. Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE?

CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES OUTCOMES IN PALLIATIVE CARE Outcomes can be understood as any end result that is attributable to health service intervention,[7] where health is defined as a state of complete physical, mental (which may include spiritual) and social well-being and not merely the absence of disease or infirmity.[8] Clearly, this fits in well with the model of palliative care. In a general healthcare context, the outcome of primary interest is often morbidity; e.g. how many patients died from having an operation of type X at hospital Y in one year. Within palliative care, this aim is less relevant, as the focus of care shifts from extending life to improving the quality of life. A range of outcomes of relevance to palliative care arise out of the holistic aims of palliative care as stated, for example, by the World Health Organization (WHO)[9] (Box 2, also see[10]). Any of these outcomes would be an appropriate focus for measurement and improvement in a clinical audit, depending on the stated aims and priorities of the service. Box 2 Examples of relevant outcomes in palliative care

Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION

REFERENCES WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? Measuring the outcomes of palliative care has five main benefits. Firstly, it enables improvement of patient and family care on a holistic and individual basis. By obtaining more detailed information about the patient and family by using formal assessment methods in day-to-day practice, healthcare providers are able to tailor and improve their care on a case-by-case basis. Secondly, assessing the outcomes of care in a formal way enables evidence to be gathered on the impact of care on the patient and family and the effectiveness of the service at meeting its aims. As palliative care is a relatively new specialty, it has much to prove! If systematically collected data is aggregated, analyzed and reviewed, it can be used as evidence of, for example, efficacy or cost-effectiveness. Through measuring the outcomes of care, studies in the US and UK have shown that palliative care improves quality of life, physical well being and symptoms including pain, spiritual well being and psychological well being.[1113] Such evidence of effectiveness can be used to justify the continuation or expansion of services and secure resources for future services, e.g. by convincing potential funders.[14] Thirdly, and most crucially in the context of this article, measuring outcomes is fundamental to clinical audit, enabling quality of care to be assessed and improved. Routine collection of data on the outcomes of care in diverse domains enables potential areas for improvement to be identified when the data are reviewed. Service managers can then utilize this data to improve practice, decide where resources should be focused, and set locally-relevant targets for quality of care for the future. Through ongoing audit the achievement of these targets can be monitored, and effective techniques to improve care can be shared with other services. Fourthly, at the national level, measuring outcomes across a range of services builds an evidence base for setting quality standards and quality indicators appropriate and feasible for different types of service across India. Quality indicators (also called quality markers) are explicitly defined and measurable items referring to the outcomes, processes, or structure of care.[15] As quality indicators are adopted voluntarily, they offer a framework for a palliative care organization to define and track its progress against its own action plans.[16] In India, where quality indicators have not yet been set and service evaluation is at an embryonic stage, there is the chance to learn from omissions in developed countries,[17,18] and ensure that cultural and spiritual aspects of palliative care, and the needs of family carers, are taken into account in national guidance and audit. Ultimately, national standards and quality indicators also need to be subjected to testing through well-designed trials.[19] Finally, the most important reason to do audit is that patient and family have a right to quality care, matter where they receive care, how that care is delivered, or who delivers the care. Whether a patient is receiving care in a hospital or at home, from trained community volunteers or from medical personnel, the quality of care should be assessed, and the service provider should be committed to its improvement. Other Sections

Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES CLINICAL AUDIT IN INDIAN PALLIATIVE CARE There has been some debate regarding the utility of conducting research, including service evaluation and audit, in developing country settings, where the funds used for such activities would, it is suggested, be better placed in feeding a hungry population.[20] However, in resource-limited contexts it is perhaps even more crucial that available resources, such as staff time and available funds, are used effectively, and that service development is evidence-based.[2123] As Higginson and Bruera state, measurement and clinical audit are one way to minimize the risk of failure, learn at an early stage about potential problems, and identify successful strategies.[21] Without auditing the outcomes of care, some important domains of palliative care may be neglected. Costs of not conducting clinical audit include providing extra, inappropriate treatment, which wastes patients and families time as well as staff time and resources; providing underutilized or inappropriate services; uncontrolled symptoms which are distressing for patients and families, and may lead to delayed discharge or preventable emergency admissions; and other unresolved problems that may cause preventable suffering.[3] For example, research indicates that in the US and UK the needs of family members are often unmet.[2426] Failure to audit family outcomes (such as family worry, confidence in caring for the patient, and adequacy of information received) may mean that they continue to be neglected.[27] The need for evaluation and monitoring of quality of care in the Indian setting has been recognized by several authors writing in this journal.[1,6,28] Anil Kumar Paleri reports that the Pain and Palliative Care Policy of the Government of Kerala favors locally relevant audit and research at various levels for improving the programs and sharing useful experience.[29] Given the recognition of the importance of evaluation, what is now needed is a clear and concrete action plan, with a commitment from the Indian Association of Palliative Care (IAPC) and service providers to create the conditions necessary for clinical audit to be carried out across palliative care services in India. While there are organizational factors

which facilitate successful audit [Box 3], an essential first step is the selection of an outcome measurement tool. Box 3 Key factors in conducting a successful audit

Other Sections Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES CHOOSING AN OUTCOME MEASUREMENT TOOL In the UK, a range of measures are used in palliative care service evaluation, the most common being the Support Team Assessment Schedule (STAS).[3,27] However, many palliative care service managers report that they have developed their own assessment tools, or used more informal methods of evaluation such as staff meetings and daily log books.[27] A disadvantage of, using informal methods of assessing outcomes Is that it is difficult to set concrete and meaningful targets which reflect the experience of care by patients and families without inviting them to participate through the use of self-completion (or assisted completion) questionnaires. Using an assessment questionnaire developed in an informal way at your own service is also problematic, as the validity and reliability of the tool is unknown. Established tools used for audit and research purposes have undergone formal psychometric testing to ensure they

are valid and reliable, i.e. measure what they set out to measure, and are appropriate in palliative care populations (for example, not too long and burdensome). The validation process aims to identify and eliminate problems in tools, such as systematic bias introduced by wording which leads the respondent to answer one way rather than another, or measurement inadequacies such as floor and ceiling effects. In addition to giving more accurate and valid results, the use of a validated and standardized outcome measurement tool across services means that results from sites with similar service models can be pooled, and results from services or service models with sufficiently similar aims can be meaningfully compared. This can contribute towards the setting of national quality standards, and may also eventually elucidate some of the strengths and weaknesses of specific service models.[4,23] In Africa, we were able to conduct audit as part of the Encompass project because of careful collaborative science beforehand to develop the APCA African Palliative Outcome Scale (POS).[33,34] The APCA African POS was based on the Palliative Outcome Scale, a tool to assess quality of care that was originally developed and validated in the UK.[3537] Working with the African Palliative Care Association (APCA) and services across Africa, this outcome measurement tool was developed and validated in a range of different settings, producing a tool that is tailored to and reliable in African palliative care. Services across the continent are therefore able to use the same tool in the knowledge that it is psychometrically valid and reflects their goals of care. Development of a similar tool in India is an essential task. The use of a questionnaire such as the POS that is specifically designed to measure the quality of palliative care helps to ensure that a wide range of relevant outcomes are assessed.[38] A survey of palliative care services in Britain and Ireland found that although physical aspects of care were audited relatively frequently (by 61% of services), other core aspects of care were rarely audited, including bereavement care (17%), training (13%), and psychological and spiritual care (12%).[27] One of the reasons for this is that the latter domains are considered more difficult to assess formally than physical aspects of care. In the UK survey, 28% of services stated that difficulty of assessment was the reason for not auditing bereavement, 33% gave that response regarding psychological and spiritual care, and 15% regarding training.[27] However, well-validated measures do exist for the assessment of these more intangible concepts, such as quality of life,[39,40] spiritual well being,[41,42] the impact of training,[43,44] and bereavement outcomes.[45,46+ As Charlton says, Unless these aspects are evaluated regularly, service providers cannot be confident they are successfully achieving their mission to promote optimal palliative care and, where possible, a good death.*27] Given the proliferation of palliative care outcome measures in recent years, it would beneficial to build on previous work and revalidate an existing measure in the Indian context. The choice of an appropriate tool would depend on the goals of the IAPC and the properties of the existing tools. However, it is important that the tool chosen for adaption and revalidation meets certain criteria [Box 4]. Box 4 Criteria for the choice of an outcome measurement tool Other Sections

Abstract INTRODUCTION MEASURING QUALITY IN HEALTHCARE WHAT IS CLINICAL AUDIT? OUTCOMES IN PALLIATIVE CARE WHY SHOULD SPECIALIST PALLIATIVE CARE MEASURE OUTCOMES OF CARE? CLINICAL AUDIT IN INDIAN PALLIATIVE CARE CHOOSING AN OUTCOME MEASUREMENT TOOL CONCLUSION REFERENCES CONCLUSION Collaboration at regional, national and possibly international levels may be required in order to establish the necessary conditions for audit in India. Establishing relevant audit systems will require close interaction between local programs with specific needs and those with audit experience and methodological skills.[21] The development and validation of an Indian palliative care outcome measure will also necessarily be a collaborative process, in order to ensure that the resulting measure is applicable and appropriate across the subcontinent. However, there are also concrete steps that service providers can make in terms of staff education and training about quality improvement, prioritization of research and clinical audit, and collaboration with the IAPC and other services to ensure quality improvement remains high on the national agenda. The IAPC has an important role to play in fostering increased service evaluation and improvement of existing services,[1] including supporting services conducting audit nationally. As a step towards this, the IAPC and Pallium India are to be congratulated for developing national standards for palliative care, reproduced in the Appendix to this paper. One of the desirable standards is that a palliative care service has a commitment to continuous quality improvement through ongoing use of a standardized audit tool (Point 34[51]). In order to meet this standard, the adaptation and validation of an appropriate outcome measurement tool is an essential next step, as recognized by the Declaration of Venice.[22] Only with such tools can relevant and applicable information regarding the effectiveness of palliative care in India be produced, and evidence-based standards and quality indicators be developed nationally.

Legal Documentation - 1 Nursing CE


Author: Kristi Hudson RN MSN CCRN Written: December 5, 2004 Updated: September 28, 2009

Course Objectives:

Upon completion of this course the student will be able to: Discuss the use of legal documentation in relation to legal protection Explain how nursing documentation impacts regulatory standards and reimbursement Describe 2 societal factors that affect legal documentation List 3 charting tips to assure documentation is accurate and correct State 3 legal aspects of nursing documentation Explain the importance of using proper spelling and grammar when documenting Discuss the risk of using unapproved and inappropriate abbreviations List the approved way of documenting 3 of the JCAHO unapproved abbreviations

Introduction In todays healthcare arena the nurse not only has a professional responsibility, but is also held accountable to document patient data that accurately reflects nursing assessment, plan, intervention and evaluation of the patients condition. In addition to this professional responsibility, nursing documentation is also significant for the following reasons: Legal Protection Nursing documentation is often the starting point in many malpractice cases. Accurate nursing documentation can either deter a plaintiff from filing a lawsuit or provide the leverage that is required to initiate one. In reviewing nursing documentation it is critical to show that the set standard of care was met. (Nursing organizations, regulatory agencies such as JCAHO and hospital policy and procedure set these standards). Jurors and attorneys view what is written in the patients record as the best evidence of what really occurred. For these reasons it is extremely important that nursing documentation is timely, accurate and complete. Regulatory Standards Joint Commission is probably the most notable regulatory agency and in recent years has embraced the concept of performance improvement that emphasizes the importance of outcomes and a multidisciplinary approach to the delivery of patient care. For purpose of Medicare and Medical funding, a healthcare facility must comply with the documentation regulations that are issued. Other

Federal regulations such as those issues by the U.S. Department of Health and Human Services must also be followed to assure that Medicare recipients are receiving the proper care. Reimbursement With the evolution of managed care, the nurses role in cost containment and charge capture has taken a strong focus. Third party payers are now not only concerned with what care was given, but also with how it was delivered. Clinical records are now scrutinized by such third party payers as Medicare, Blue Cross/Blue Shield, etc. to be sure that the billed service was not only delivered, but that it was actually required in the first place. Without accurate and compete nursing documentation that clearly describes service and treatment, healthcare facilities stand to lose substantial revenue through denied reimbursement.
Societal factors that affect nursing documentation include: Increased Consumer Awareness The media, popular magazines and healthcare based organizations are putting forth great energy to assure that the healthcare population is aware and informed about nursing issues and treatment options. The healthcare consumer is now demanding high quality care that can be given at a reasonable cost. Consumers now expect nurses to be knowledgeable, competent and at some levels flawless in their delivery of care. Because of this newfound public knowledge, it is absolutely necessary that evidence of this high quality care be reflected in all nursing documentation.

Increased Acuity of Hospitalized Patients Because of changes and reimbursement in payer mix (third party insurers), the outpatient setting has seen a large growth of consumers, which has increased the acuity of the in-patient immensely. Also increasing the acuity in the inpatient setting is the elderly population that is being cared for. This patient population presents with more complex and chronic issues. With the elderly population, additional nursing documentation is usually required, and this needs to include plans for the patient after discharge.

Increased Emphasis on Outcomes Prospective payment systems, medical malpractice lawsuits and limited healthcare resources has made the quality of healthcare a major issue. Cost containment (avoiding unnecessary expenditure), renewed sense of competition (comparing outcomes with quality and price), and recognition of geographically variant standards (different regions provide different services). It is documentation that is the main mechanism of gathering this data. If you

have heard of a new charting trend called outcome charting, it is this type of information that organizations are trying to capture.
Documentation should include the following (Charting Tips):

Direct quotations from the patient, family or visitors Data that has been gathered Actions taken Individuals notified about concerns and issues Evaluation of Actions First, making sure you have the correct chart (MOST IMPORTANT PRIORITY) Writing neatly and legibly (with blue or black ink) Conveying significant details Signing and dating every entry Using proper spelling, grammar and appropriate medical phrases Using authorized abbreviations only Assuring patients name is on every page A single line through entry errors and your initials (no erasing or white out)

Legal Aspects of charting should include:

Nursing documentation and progress notes that are filled with misspelled words and poor grammar create a negative impression. Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless.

The following are true examples of spelling errors noted on nursing flow sheets:

MD order: Walk patient in hell. Patient lying on eggshell mattress. Fecal heart tones heard. Patient observed to be seeping quietly. Foley draining fowl smelling urine.

The following are true examples of errors in grammar and incorrect use of words noted on nursing flow sheets:

MD order: May shower with nurse Patient has no rigor or chills, but husband states she was hot in bed last night Large BM up walking in the hall Patient had a cabbage done The pelvic exam was done on the floor Vaginal packing out, Doctor in

Skin Somewhat pale but present

In addition to taking care to use appropriate grammar and use of words, it is also important to avoid writing inappropriate comments on the nursing flow sheet. Finger pointing and accusations of incompetence are surely a red flag to lawyers and jurors. Evidence of fighting among healthcare professionals in the nursing documentation is just what a plaintiffs lawyer is looking for. The following are true examples of inappropriate comments found in nursing and physician documentation:

IV infiltrated because nightshift forgot to check it Patient going into shock, could not reach Dr. Jones per usual Physician Note Once again, the lab forgot to draw the patients PTT this am Physician Note If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here Patient received insufficient care today because nurse patient ratio was 1:7 Physician Note: Patient fell due to lax nursing supervision Patient in extreme pain because previous nurse too busy to give pain meds

The Risk of abbreviating in legal documentation:

When documenting, its imperative that you dont put your patients life at risk because of the abbreviations that you use. Abbreviations can be extremely dangerous to you and your patient, besides being a major waste of time.

The following are reasons why you should avoid abbreviations:

Abbreviations can be a total mystery to the reader. If a physician wrote, Patient may get up AFAWG, would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still wouldnt have the correct answer. (For the record, this was a physician order and AFAWG means As far as wire goes).

Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use u for units. Another critical error can occur with the use of ug, for microgram, which has been misinterpreted to mean mg, for milligrams. Errors such as

these occur more frequently then we would like to admit, and all because someone used and unclear abbreviation.

The less space you have for documentation, the more inclined you may be to abbreviate. Make sure that there is adequate space on your flow sheet for your documentation. The tendency is to force a lot of information into small spaces, thereby avoiding having to document in the progress notes. The results are often creative or imaginative but useless, wasteful, and uncommunicative.

JCAHO Standard for Approved Abbreviations:

It has been reported that as much as 15% of the medication error reports received by the NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) have occurred because of illegible handwriting, problems with leading and trailing zeros, misinterpreted abbreviations, and incomplete medication orders. To "improve the effectiveness of communication among caregivers," JCAHO is requiring facilities to develop their own list of abbreviations, acronyms, and symbols that should not be used. In addition to facilities individual choices, JCAHO has published a list of unapproved abbreviations that must also be adopted. The following chart includes the JCAHO unapproved abbreviations list which gives suggestions, mandates and expansion options:

Articles Nursing documentation must make sense, must have meaning, and must communicate.
Effect of Poor Documentation
Has poor documentation impacted patient care in your facility? Has the use of bad abbreviations wasted time and detracted from patient care? (See the article Abbreviations: A Shortcut to Disaster on this page for more on the topic.) Has your organizations' bottom line been affected because

Abbreviations: A Shortcut to Disaster


This article poses some interesting thoughts for your staff and the use of abbreviations in their documentation. Are they hurting the patient, themselves, and your

equipment, medication, or treatments were not properly documented? If you completed a patient assessment and then looked at a previous assessment, could you make a better decision about what to do next for the patient? If the previous assessment was properly documented, the answer would be yes. But if the previous documentation was incomplete, then the employee would have a hard time making a good decision! Documentation does impact the quality of care given. Maybe the reason for the complaint that "no one reads our charts" is because nurses do not say what needs to be said! Documentation must be accurate, clear, concise, complete, and timely. Speed is of the essence when working in healthcare, but accuracy and completeness are imperative when documenting. Do not let the patients health be compromised by worrying about the speed; make sure it gets done right the first time. Documentation must have meaning today, tomorrow, and in the unforeseen future. One of the difficulties with documentation is that we never know when what we document will be needed. You want to make sure the right information gets documented and that documentation is done correctly. Nursing documentation is important and not just for legal purposes. The results and benefits of nursing documentation are greater than the sum of the tasks themselves. It isnt an easy task, but it is necessary and it is a way of giving high-quality patient care. The lack of proper documentation can negatively impact patient care and can ultimately cause other problems. This was shown with nursing research done by Paice, et al., who found that pain management of surgical oncology patients was inadequate. They stated that the lack of documentation they found in their study led to a "...lack of consistent care and the inability to evaluate the effectiveness of pain therapies."1 Their research becomes even more important in light of new consideration of pain as the fifth vital sign and JCAHOs emphasis on pain management this year. Continued

organization?

Are you putting your patient at risk


by using abbreviations? Are you putting your career at risk by using abbreviations? Nurses are supposed to be communicators, especially when documenting patient information. If what we write does not communicate, then we have failed in our professional and legal responsibilities. Furthermore, we have failed our patient and our employer, thereby putting all at risk. When documenting, it is imperative that we do not put our patients lives at risk because of the methods we use for the task. These methods include the use of abbreviations. The indiscriminate use of abbreviations can be extremely dangerous to the patient and the nurse and a major waste of time. 1. Abbreviations can be a total mystery to the reader. If a doctor wrote "Patient may get up AFAWG," would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still would not have the correct answer. 2. Abbreviations are easily confused. Patients are still being overdosed with insulin

and heparin because people use "u" for units. Another critical error can occur with the use of "g" for "microgram," which has been misinterpreted to mean "mg" for "milligrams." Any of these situations could lead to a serious medication error and catastrophic results for the patient. How would you like to write the incident report on the newborn who received ten units of insulin instead of the one unit he was suppose to receive? This type of error automatically multiplies the dosage by a factor of ten. 3. Next, abbreviations that start out as time-savers can end up as time-wasters. As nurses, we often use abbreviations to speed documentation. But does the reader get our intended message? Ask three nurses what "pt voided qs" means. One might tell you "voiding quantity sufficient" and another one might say "voiding every shift." Try this abbreviation: "MSO4." Did you say morphine or magnesium? I have received both answers in every class where I asked the question. The differences in these interpretations could have devastating consequences. Continue

Adv Nurs. 2011 Sep;67(9):1858-1875. doi: 10.1111/j.1365-2648.2011.05634.x. Epub 2011 Apr 6.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review.
Wang N, Hailey D, Yu P.

Source
Ning Wang RN PhD Candidate Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia David Hailey PhD Research Fellow Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia Ping Yu PhD Senior Lecturer, Research Director Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia.

Abstract
wang n., hailey d. & Quality of nursing documentation and yu p. (2011) approaches to its evaluation: a mixed-

method systematic review. Journal of This paper reports a review Advanced Nursing 67(9), 1858-1875. ABSTRACT: Aims. that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and Quality describing the quality status of nursing documentation. Introduction. nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings. Data sources Searches were made of . seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify A articles published in English between 2000 and 2010. Review methods. mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative Seventy-seven publications were included. synthesis was conducted. Results. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its Research should pay more attention to the accuracy of quality.

Conclusion. nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

2011 Blackwell Publishing Ltd.

PMID: 21466578 [PubMed - as supplied by publisher]

The study of nursing documentation complexities.


Cheevakasemsook A, Chapman Y, Francis K, Davies C.

Source
Adult and Geriatric Nursing Department, Faculty of Nursing, St Louis College, Yannawa, Bangkok, Thailand.

Abstract
This study aimed to explore complexities in nursing documentation and related factors. Nursing documentation has been one of the most important functions of nurses since the time of Florence Nightingale because it serves multiple and diverse purposes. Current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of quality of patient care. However, nursing documentation has not served such objectives because of its complexities. This study explores nursing documentation complexities and related factors through both qualitative and quantitative methodologies. The study used multiple methods of inquiry: in-depth interviewing; participant observation; nominal group processing; focus group meetings; time and motion study of nursing activities; and auditing of completeness of nursing documentation. Complexities in nursing documentation include three aspects: disruption, incompleteness and inappropriate charting. Related factors that influenced documentation comprised: limited nurses' competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development. These findings suggest that complexities in nursing documentation require extensive resolution and implicitly dictate strategies for nurse managers and nurses to take part in solving these complicated obstacles.

Documentation For The Nursing Professional Essay


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Documentation For The Nursing Professional


Submitted by lwishmier on March 20, 2011

Category: Science And Technology Words: 1518 | Pages: 7 Views: 165 Report this Essay

Documentation for the Nursing Professional Lindsay Wishmier Nursing 232 Professor Steve Keiser October 29, 2009 Documentation for the Nursing Professional Documentation is a critical aspect in nursing. Documenting covers everything in regards to a patients care and stay in a facility. There are many things that need to be covered when documenting the care of a patient. Most of these things are related to treatments, medicine, procedures, doctor visits, and problems of the patient. There are also many skills to take into account when documenting. A patients chart is filled with information from all aspects of their care. Looking through the chart, information is gathered from other health care individuals on their treatment of the patient. Documentation can be a big source of communication, when staff is not able to be face to face. Documentation needs to be relevant and have important information included, without going into the color of the patients shoes. You must Login to view the entire essay. If you are not a member yet, Sign Up for free! Documentation is one of the most important responsibilities of all health care providers. Its a means of communicating among health care team members and the primary way by which nurses

record factual information about a patients status and the care provided from the time of admission to follow-up after discharge (Lippincott 2007). The importance of documentation is critical. As stated before it is a legal document. So think of documenting like presenting your patient to a lawyer and even a judge. Basics need to be included within a certain degree as well as the importance of care. Documentation needs to always be started with a date and time of entry. Try to document as soon as possible to avoid missing critical information. Include documenting what the patient tells you; quote the patient directly (Mosby 2006). Document what you assess and what you do, following with the patients response. Document all teachings, plannings, and outcomes for the patient (Mosby 2006...

The importance of good record-keeping for nurses


14 January, 2003 Nurses are subject to increasing scrutiny regarding their record-keeping. Legislation such as the Human Rights Act 1998 and the Data Protection Act 1998 has increased the profile of, and access to, health records (Dennemeyer, 2000; Sainsbury Centre for Mental Health, 2002), while patients are increasingly willing to complain about their care. Whether complaints are resolved by health care providers or settled in court, comprehensive records are essential. VOL: 99, ISSUE: 02, PAGE NO: 26 Christopher Wood, BA, RMN, RGN, is practice development nurse, Rampton Hospital, Nottinghamshire It is important, therefore, that nurses keep abreast of legal requirements and best practice in record-keeping. The Code of Professional Conduct (NMC, 2002a) advises that good note-taking is a vital tool of communication between nurses. It states that nurses must ensure that the health care record for the patient or client is an accurate account of treatment, care planning and delivery. It should be written with the involvement of the patient or client wherever practicable and completed as soon as possible after an event has occurred. It should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared. It is significant that allegations concerning shortcomings in nurses record-keeping were the second most common category of hearing brought before the UKCC in 2000-2001 and were surpassed only by allegations of abuse (NMC, 2002b; UKCC, 2001).

The legal perspective


The cost to the NHS of litigation rose from 2.3bn in 1998 to 4.4bn in 2001 (National Audit Office, 2002). Litigation is already regarded as an occupational hazard for medical staff, and it is estimated that at least one in three other health professionals will be involved in some kind of legal proceedings at some point in their career.

Law courts adopt the attitude that if something is not recorded, it did not happen and, therefore, nurses have a professional and legal duty to keep records. The NMC (2002c) states that documentation should demonstrate:

- A full account of the nurses assessment and care planned and provided for the patient; - Relevant information about the condition of the patient at any point; - Measures the nurse has taken in response to the patients needs; - Evidence that the nurse has understood and honoured the duty of care, has taken all reasonable steps to care for the patient and that any action or omission has not compromised patient safety; - A record of any arrangements the nurse has made for the continuing care of a patient or client.

Nurses face new issues and problems each day and regularly make decisions on patient care. Each decision is potentially subject to review with the publics increasing awareness of their rights and tendency to litigate. Amid the stress of a working day, it is easy to see how record-keeping might be seen as a chore that gets in the way of patient care. However, it is an integral part of care. Nurses must allocate time for both hands-on care and documentation, as it is the two together that constitute total patient care. If record-keeping is seen as a chore, there is a risk that the documentation will fall short of the standard expected of a professional. A nurse who has cared for hundreds of patients could not possibly remember details about the care provided to a particular patient several years - or even several weeks - later. However, the circumstances are likely to be fresh in the memory of the patient making the complaint. Good documentation can therefore be a vital means of recollection for nurses faced with litigation. Detailed and substantial evidence is likely to be influential in such circumstances; nurses whose memories of events are poor and who have not documented their actions clearly may find their position compromised. Having good quality records to refer back to enables the nurse giving evidence to relate as precisely as possible what happened. Long before a legal case becomes a formal hearing, the nursing notes will have been read and studied and an impression formed regarding the relative professionalism of the author. If records are clearly unprofessional it is easier to extrapolate that the same lack of professionalism would be reflected in attitudes towards patient care. Any notes or records taken in the course of a nurses work are a potential legal document and could be used in court. If they contain judgemental, vague or unsubstantiated information, it becomes difficult to maintain professional credibility in court. It is the job of a patients lawyer to undermine a nurses case by casting doubt on that nurses credibility. Lawyers are familiar with court cases and professional hearings - two scenarios that may be extremely intimidating for those who are not.

The implications for colleagues


Nurses should also bear in mind, when compiling records, that their colleagues rely on the information they record when taking over a patients care. This can resolve any uncertainty over

how much to write in patients notes. The frequency and content of entries is determined both by a nurses professional judgement and local standards, but an acid test is: If a nurse were coming to care for a patient for the first time, what would they need to know? Colleagues should be able to look at a nurses notes and continue caring for the patient in a seamless continuum. If a named nurse was unable to return to work, then from the patients point of view this should make no difference to the care they receive. Nurses are also professionally accountable for ensuring that any duties they delegate to unregistered staff are undertaken to a reasonable standard. For example, if a nurse delegates record-keeping to students or nursing assistants, she or he must ensure that they are adequately supervised and capable of carrying out the task. The nurse is accountable for the consequences of those records and such entries must be clearly countersigned. How to improve record-keeping By adopting the following habits, nurses should avoid problems related to record-keeping:

- Get into the habit of using factual, consistent, accurate, objective and unambiguous patient information; - Use your senses to record what you did, such as I heard, felt, saw, and so on; - Use quotation marks where necessary, such as when you are recording what has been said to you; Ensure there is a reasoned rationale (evidence) for any decision recorded, for example, denying access to a visit from children; - Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry (initials should be avoided); - Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar when planning care; - Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any subsequent alterations or additions; - Document any objections you may have to the care that has been given; - Do not include jargon, meaningless phrases (for example slept well), irrelevant speculation, and offensive subjective statements; - Write the notes, where possible, with the involvement and understanding of the patient or carer (NMC, 2002c).

Expressions such as had a good day should not feature in isolation. Notes should explain why the patient had a good day - for example, if a relative visited or the patient was lively and interacting with staff and other patients (Dimond, 1999). There are also misconceptions around the use of subjective words such as appears. This cannot be used as a factual observation such as appeared unsteady on his feet - a patient either is or is not unsteady on his feet. However, such an expression could be used where the facts would be impossible to establish, for example a confused and inarticulate patient who appeared to be experiencing auditory hallucinations. The nurse could not be certain what the patient was experiencing, but would need to elaborate and describe the behaviour that led to this conclusion.

Errors should be corrected by putting a single line through the incorrect statement and signing and dating it. If records are used in evidence, it must be clear what was originally written and why it was changed, therefore correction fluids should not be used. Sometimes professionals may face conflicting ethical pressures - for example it may be considered kinder not to keep informing a patient with dementia that they are in hospital under a section of the Mental Health Act when they repeatedly ask where they are. Provided that nurses know what they are doing and why, and are prepared to justify it, this should not cause undue legal problems (Andrews, 2002; NMC, 2002c; Department of Health, 1999). Ultimately, professional nurses must be able to justify why they have taken a particular course of action. The NMCs position on abbreviations is that they should not be used (NMC, 2002c). However, a number of everyday medical abbreviations are used appropriately and safely, such as BP (blood pressure). To write these in full each time would add considerably to the time taken to complete records. However, there are dangers in the use of abbreviations. For example PT could mean patient, physiotherapist or part time; BD could mean twice or brought in dead. Misunderstandings can be avoided by generating an agreed list which is reviewed regularly. This list should be attached to patients records (Andrews, 2002; NMC, 2002c; Dimond, 1999).

Conclusion
Vigilance is required to ensure high standards in record-keeping, whether records are in written or electronic form. The audit of patient documentation is a facet of risk management, and can help to promote quality (NMC, 2002c) as it means standards can be assessed and areas for improvement identified (Dimond, 1999). Maintaining good quality records has both immediate and long-term benefits for staff. It can directly benefit them, for example in respect of safety, by promoting the early identification and appropriate treatment of potentially violent patient behaviour. In the long term it protects individuals and teams from accusations of poor record-keeping, and the resulting drop in morale. It also ensures that the professional and legal standing of nurses are not undermined by absent or incomplete records, if they are called to account at a hearing. Good record-keeping promotes better communication as well as continuity, consistency, and efficiency, and reinforces professionalism within nursing. For the sake of patients and colleagues - as well as their own protection and peace of mind - every nurse should get into the habit of recording their actions and observations accurately and professionally.

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The importance of documenting family history


1. Patricia Kelly, DNP, APRN, CNS, AOCN + Author Affiliations

1. Dallas, Texas.

As Dr Alspach pointed out in her February 2011 editorial, 1 family history assessment is an important, inexpensive, and often underutilized genetic tool. I recently studied family history assessment and documentation in 3 gastroenterology units2 and found deficiencies. Others have noted deficits in these areas as well. For example, according to the Secretarys Advisory Committee on Genetics Health and Society Draft Report on Genetics Education and Training, 3(p15) family history proficiency is not a competency required in order to graduate from a medical education program, and only 22 percent of 46 Advanced Practice Nursing students in nurse practitioner programs felt they could draw a family pedigree. Accurate documentation of nursing care and patient histories has long been a challenge. We all had hoped that the electronic health record (EHR) would facilitate assessment and documentation. Unfortunately for many health care systems, this has not been a reality.4 The EHR has the potential to capture family history information, create pedigrees, update and share information among providers, quantify risk, and connect with decision support tools. However, many EHR systems actually interfere with assessments. Documentation of red flags (eg, disease age of onset for an affected relative, degree of relative, and number of affected relatives) should be cued and easily accessible in the health record but, usually, it is not. In my study, cancer family history age of onset was often missing; this is critical information to target genetic referrals and individualize cancer screenings. I found family history information in a variety of places in the medical record, and there was sometimes contradictory information. We have entered the genetics/ genomics era. All nurses should be able to assess family history information, facilitate genetic referrals, and incorporate risk information into a plan of care. Many resources are available; for example, the National Coalition of Health Professionals in Genetics has established family history and genomic competencies (including pedigree development) for all health care providers along with corresponding instructional modules.5 Nursing-specific family history competencies and educational resources are outlined in the American Nurses Associationendorsed

Essentials of Genetic and Genomic Nursing: Competencies, Curricula Guidelines, and Outcome Indicators.6
Family history is one of the most important genomic tools. Each of us needs to know how to do an accurate family history assessment and where to document it.

2011 American Association of Critical-Care

Legal Aspects of Nursing


By Amanda Bog
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As a nurse it has become an important necessity to be aware of the legal aspects associated with caring and helping people in the health industry today. Unfortunately, the more and more negligence cases there are the less and less people want to get into the health care field fearing legal aspects and the inevitable law suites. The first nursing law created was that of nursing registration in 1903 and they have only evolved and expanded over the years to create a thick book which must be studied today by aspiring nurses. The Tort Law is the legal aspects of the law that most nurses are more familiar with. This is the law that involved malpractice and negligence cases which many nurses take the time to learn inside and out as this is one of the biggest fears in the medical community. Basically a Tort is a wrongful act which produces harm, whether it is unintentional or intentional. Malpractice is a specific type of Tort where the standards of care are not met. This is one of the most common and familiar laws to nurses and something that nurses and doctors alike must be familiar with in order to continue their care efficiently. In order to protect you from malpractice suits, nurses must take as many precautions as they can during their daily shifts. Recording, documenting and reporting your daily routines and decisions is one of the most common ways to make sure you are on track with your patience and in the right. Nurses learn in school that proper care of a patient is not only making the right decisions but maintaining and organizing their medical records and reports efficiently. Any nurse who is not able to provide written proof of their decisions and why that decision was reached will no doubt be charged with nurses' negligence and risks being seen in front of a court. The legal aspects of nursing are taught and expected to be kept up on throughout every nurse's career. Employment as a nurse does not only require a nursing degree but knowledge of the

medical laws that will apply to you should there is a misunderstanding or challenge by a patient or their family. A nursing job is something many young people aspire to but without the legal knowledge behind them, many hospitals will not hire them now that legal issues are becoming more and more problematic. http://www.travel-nursing.net/ http://www.legalaspectsofnursing.freewebsitehosting.com/ http://www.nursing-education.coolpage.biz/ Article Source: http://EzineArticles.com/?expert=Amanda_Bog

Strategies to improve nursing documentation* The form your facility chooses makes a difference in the quality of documentation
Renew

Learning objectives: After completing this exercise, you will be able to: 1. identify the advantages and disadvantages of narrative documentation 2. describe the benefits of using checkbox/template documentation 3. recognize electronic documentation's strengths and problems When deciding which type of form to use for nursing documentation, first weigh the inherent positives and negatives of each general type--narrative, template, and electronic. Above all, documentation forms must be efficient, comprehensive, and reasonable, and must prompt nurses to document appropriately, says William Malm, ND, RN, president of Health Revenue Integrity Services, Inc., in Cleveland. For some documentation do's and don'ts, click here. And for some common mistakes to avoid, click here. Narrative documentation A narrative documentation form is essentially blank and the nurse simply writes in all of the pertinent information. These types of forms are based on the SOAP (Subjective, Objective, Assessment, and Planning) template. This is the least effective form because it is completely up to the nurses to decide what they document, Malm says. In addition, this form is not easy or efficient to use, because nurses must write everything out, rather than simply checking boxes next to descriptions of the services provided. "It's very inefficient and leads to a lot of documentation errors," says Malm. However, narrative forms are flexible, especially for documenting complications, new diagnoses, and other unforeseen occurrences. Checkbox/template documentation A template form of documentation--which usually combines a string of checkboxes with an area for narrative notes--is a convenient, efficient, and comprehensive approach. Because nurses can simply check boxes as they provide care, these forms also remind staff what they need to document. The addition of a narrative area allows nurses to make extra comments about the care or any unforeseen complications. "The checkbox method is the most efficient by far, because you can just go down the line and see the whole thing--it's not on separate pages or on a computer," says Malm. "It allows you some more flexibility but still leads the nurses to complete it in the same fashion, thereby ending up with the data that you require." But even checkbox documentation has limitations when it's paper-based. "[With a] paper chart,

I've got medical records, the respiratory therapist, the physician, the physician's assistant, [and] the nurse. All of those people are going to want that medical record at the same time," Malm adds. Electronic documentation Despite the fact that many hospitals have not yet made the transition to electronic health records (EHR), Malm says he prefers this means of documentation for several reasons. First, you can customize EHRs to capture whatever information your facility deems necessary. Although electronic documentation presents flexibility problems (e.g., once set up, electronic documentation templates can be difficult to alter), it promotes the capture of uniform documentation. Although the cost associated with transitioning to an EHR can be a drawback, it eliminates filing loose paper and retrieving records. Read about the learning curve here. EHRs are optimal for dealing with litigation, audits, and patient care, Malm says. With paper records, medical records and health information management have the burden of maintaining, filing, and retrieving charts as well as tracking the paper records' location when in use. EHRs comply with Health Insurance Portability and Accountability Act of 1996-related requirements and provide appropriate caregivers access to the records, says Malm. "With the paper method, the physicians have the charts, and you may not have that immediate opportunity to document, so you forget it or don't do it," says Malm. "With an EHR, you just go to a computer screen and view the chart. Everybody has access immediately, which makes the process more efficient and prevents lost documentation, [which is a] key to exceptional clinical care, fundamental reimbursement, and litigation support." Source: Briefings on APCs, September 2006, HCPro, Inc. Resources: 1. "Do's and Don'ts of Nursing Documentation" at http://medi-smart.com/documentation.htm 2. "8 Common Charting Mistakes To Avoid" at http://www.nso.com/newsletters/features/common.php 3. "Software Simplifies Charting, but There's a Learning Curve" at http://news.nurse.com/apps/pbcs.dll/article?AID=/20070226/PHILADELPHIA09/702260305/100 9/PHILADELPHIA

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