ED nursing documentation: Read, react, and reconcile
ED nursing documentation: Read, react, and reconcile
Janet L. Finley, MS, RN, CNS, Certified Clinical Nurse Specialist, Department of Nursing; Saint Mary's Emergency Department, Mayo Clinic, Rochester, MN; and Eric T. Boie, MD, FAAEM, Vice Chair and Clinical Practice Chair, Department of Emergency Medicine, Mayo Clinic; Assistant Professor of Emergency Medicine, Mayo Graduate School of Medicine, Rochester, MN
Editor's note: Ever present in the health care provider's training and practice is the continual responsibility to provide documentation. Although it is ever drummed into our heads that proper documentation is necessary for the purposes of billing, quality assurance, and risk management, documentation is also important in real time for the purposes of communication among caregivers. Not only must each health care practitioner record his/her own activities and findings related to a patient's care, but each practitioner also must take heed of every other provider's documentation. It is dangerous to neglect to read another provider's notes related to the ongoing care of a patient. Overlooking someone else's findings —whether accurate or inaccurate — may lead to pitfalls in the care of the patient. Furthermore, failing to address another practitioner's notes — whether consistent or inconsistent with one's own — may provide fodder for a malpractice attorney's appetite when a medical record is reviewed in the course of a malpractice suit. This month's ED Legal Letter reminds us of the pitfalls that may arise with the process of nursing documentation. Whether the reader is a physician, a nurse, or another health care provider, the lessons learned from this month's issue have immediate practical application in our everyday practice of medicine. — Richard J. Pawl, MD, JD, FACEP (Dr. Pawl is Assistant Professor of Emergency Medicine Medical College of Georgia, Augusta and Editor-In-Chief of ED Legal Letter.)
Introduction
The medical record serves clinical and nonclinical functions in every health care setting. In its most basic sense, it provides chronological documentation of a patient's clinical care and is a method of multidisciplinary communication.1 Documentation should reflect the specific facts, procedures, and care that occurred. It is inseparable from actual physician and nursing care rendered.2 Documentation will serve as the primary defense should litigation be pursued.
In a fast-paced setting, such as an emergency department (ED), complete, accurate, and succinct documentation is imperative. Health care professionals often view documentation as a burden, considering it a task of low priority because it takes away from time with the patient. However, it is crucial to the communication and critical decision making necessary in meeting patient needs.3 One erroneous notation in the medical record can lead to a chain of deadly treatment decisions.4 A cavalier attitude toward documentation may lead to a disaster clinically or in a court of law.
The frantic pace of the ED causes emergency physicians and nurses to document encounters inadequately, improperly, or sometimes not at all.4 As the number and complexity of ED patients steadily increase, nurse and physician providers are challenged to maintain the same high level of teamwork and quality of care. Documentation needs to reflect effective and close communication of team members.
The purpose of this article is to examine ED nursing documentation and the emergency physician's interaction with it. Cases will illustrate the critical value of ED nursing documentation and underscore the need for the emergency physician to review, acknowledge, be responsive to, and resolve any discrepancies in real time.
The Value in Reading…Acknowledgment of RN Documentation
Case #1: Powell, Administrator v. Oeters and Beaufort Emergency Medical Associates5
A 59-year-old male presented to an ED after experiencing 24 hours of body aches and fevers unresolved by ibuprofen. The triage nurse documented a splenectomy as part of the patient's past medical/surgical history. Temperature on presentation was 103.6°C along with an elevated blood pressure and heart rate. The physician found no source of infection and made the diagnosis of a viral syndrome. The patient was given two liters of crystalloid and Tylenol while in the ED. Discharge instructions advised administration of Tylenol and Motrin along with plenty of fluids. Later that day, the patient was found unresponsive at home. He was taken to the ED and pronounced dead just 12 hours after being discharged from his initial visit.
A suit was filed, and at trial the physician stated that she did not know that the patient was asplenic and also was not aware that a splenectomy was a predisposing factor to systemic infection. A settlement was reached for $850,000.
Discussion
The medical record provides the entire health care team a comprehensive picture of the patient's condition and the care delivered.2 Documentation —whether written or in computer format — is the means of communication that ensures and represents that critical pieces of information gathered were conveyed to others providing care. Failure to carefully review what nurses and other providers have documented can lead to negative patient outcomes1 and exposes the emergency physician to substantial medicolegal risk.6 Pleading unawareness because nursing documentation was not reviewed is essentially indefensible. The above case demonstrates the horrible clinical and legal outcomes from this inexcusable oversight.
Coordination of care is paramount in the ED setting due to patients' diverse and complex presentations, a lack of familiarity with patients' medical history, and the need to make rapid decisions based upon limited clinical information. A close and good working relationship between physicians and nurses is essential in providing good patient care. An integral part of a good working relationship is effective communication and that includes the emergency physician carefully reviewing all nurses' notes regarding patient care.7 The pressure of time, and in some cases the format of the ED record, can make routine review challenging, but the importance of this step cannot be overstated. Initialing the nurses' notes or somehow electronically indicating completed review is advisable. Not only will nurses appreciate this acknowledgment, but this action also demonstrates on retrospection a verifiable, real-time review of nursing documentation.
In efforts to make multidisciplinary documentation more accessible and organized, the electronic medical record (EMR) increasingly is being integrated into many ED settings. The potential benefits of the EMR have been widely touted including enhancing patient safety, reducing medical error, increasing efficiency through automatic prompts, streamlining workflow, and supporting quality assurance and surveillance efforts.8 While, ideally, the EMR sounds like an exceptional advancement, its true impact on patient care and on communication among providers is unknown. EMRs with cumbersome interfaces or those that result in nursing notes that are more difficult to access or view may slow and impair physician review. Furthermore, it has been noted that physicians who have relied upon verbal reports are no more likely to access the electronic EMR than they did with the paper record.9 Regardless of the method of documentation, standards of documentation and the need for review remain.
Case #2: Love v. Rancocas Hospital, et al.10
Ms. Love arrived at a New Jersey ED by ambulance at 5:00 pm after experiencing episodes of syncope, falling, and poorly controlled high blood pressure. She was treated by the ED physician, and her blood pressure readings were 133/94 mmHg, down from 200/110 mmHg on presentation. She was instructed to discontinue taking her regularly scheduled atenolol and to follow up with her primary physician in three days. The patient was discharged but remained in the ED patient care area for an ambulance to take her home. During her wait, at approximately 8:40 pm, Ms. Love fell off the bed where she was sitting. The ED nurse obtained her blood pressure at that time with readings of 180/110 mmHg and 170/100 mmHg. The patient was taken home by ambulance at approximately 10:40 pm.
Two days later, Ms. Love was taken back to the ED for the same symptoms in addition to right-sided weakness, slurred speech, and facial droop. She was admitted to the hospital and was diagnosed with a stroke.
Ms. Love filed suit, and her attorney argued that the patient had suffered a stroke after being discharged from the ED on her initial visit with unstable high blood pressure. The ED nurse testified that she had documented the blood pressure readings at the time of the fall. She also stated that she had informed the physician of the event but had not documented that fact in the medical record. The physician testified that he was unaware of the fall, and that if he had known that the patient's blood pressure readings were that high, he would not have allowed her to leave. This case was dismissed due to an exceeded statue of limitation.
Discussion
Failure to report a significant change in a patient's condition to the physician is one of the most common charges levied against ED nurses.11 Documentation of changes in patient status is crucial, but when significant changes occur, the nurse is compelled to notify the physician.12 Appropriate assessments and reassessments, along with timely reporting to a physician, may substantially affect patient outcomes.1 Nursing responsibility does not end with documentation of clinical symptoms, which in this case was the patient's fall and subsequent blood pressure readings prior to dismissal.13
A study that reviewed nursing malpractice suits found that inadequate communication between the nurse and physician was the predominant problem that caused adverse outcomes as well as death.2 Regarding the case of Ms. Love, although the ED nurse documented the two subsequent blood pressure readings after the patient fell, there was no written documentation that the physician had been notified. The reported verbal communication was called into question. Ultimately, the physician remains responsible for review of vital signs and changes in patient status; the "nurse didn't tell me" is not a sound defense.
However, the lack of clear documentation of notification of changes in this case pits physician against nurse in "he-said, she-said" fashion. It serves only to demonstrate to a jury that this team was ineffective in communicating and perhaps in delivering care as well. Furthermore, studies have demonstrated that written documentation is believed by juries more than oral testimony.14 Subsequent cases will further examine communication breakdowns.
The Need to React… Impaired by Communication Breakdowns
Case #3: Anonymous v. Anonymous Triage Nurse, Anonymous Emergency Room Physician15
A 15-year-old male presented to the ED with his mother three hours after being "jumped" by three people. He stated that he had been struck in the head during the assault. The nurse noted pain in the patient's right temple and that he had experienced dizziness prior to presentation, but there had not been any loss of consciousness. On presentation, blood pressure levels were slightly elevated. The nurse gathered information on the patient's past medical history. Next to the phrase "clotting disease history", he documented a zero with a diagonal line through it, and then an arrow through its entirety. The patient waited three hours to be seen by a physician; during this time he vomited and later vomited during the medical examination. X-rays of the patient's jaw were the only diagnostic studies ordered, which confirmed that the jaw was not fractured. The physician recommended that the boy see a dentist for impacted wisdom teeth and then dismissed him with instructions to return if any "vomiting or headaches should occur." He instructed the patient's mother to give him two Tylenol tablets every four hours and to apply ice to the affected area. Later that evening, the mother was unable to arouse her son from sleep, and he was found to be unresponsive by emergency medical providers. A CT scan confirmed a temporal-parietal subdural hematoma. Intracranial pressures continued to increase, and the patient underwent an emergency craniotomy for the evacuation of the subdural hematoma. Clotting studies showed that the boy suffered from Factor VIII deficiency (hemophilia). The patient was permanently neurologically impaired.
At trial, the nurse testified that his note regarding the patient's past medical history intended to show that initially there was believed to be no clotting problems. However, later in the assessment the patient was found to have a clotting problem history. The arrow was added at that time as a means of correcting the original entry. The defendant physician stated that the nurse's note of past medical history was unclear, which caused him to interpret the information incorrectly. The settlement was for $3.25 million.
Discussion
Physicians must be prepared to react to and act upon findings documented in nurses' notes. This is the natural next step beyond simple review because nurses' notes contain information that may not be routinely gleaned on the physician's interview of the patient. Nursing documentation must be of high quality. Janet Miller, in her article entitled "Nursing Documentation: Standing Up to the Scrutiny of Medical Malpractice", emphasized that charting by nurses should be 1) factual – objective and free of opinions or assumptions, 2) intact – no portions discarded or obliterated, 3) specific – especially times, treatments, responses, and notifications, and 4) clear and concise – using only approved abbreviations.16
The unfortunate outcome in the case above hinged upon the use of a personalized symbol that subsequently was misinterpreted by the emergency physician. Utilizing personalized nonstandard abbreviations or symbols when documenting poses significant risk for misinterpretation, whereas utilizing standard abbreviations reduces the likelihood of clinical error.4 Discussions of standardized abbreviations have been a part of Joint Commission Accreditation of Health Care Organization's (JCAHO) safety goals for the past two years. Organizations should have a well-established list of prohibited abbreviations that are not allowed in any portion of the medical record.17 Personalized abbreviations should never be used no matter how timesaving they may seem.14
Beyond personalized symbols and abbreviations, this case also raises the issue of how to appropriately correct errors in charting. Errors should never be obliterated but should be struck through with a single line. Proper information should be placed in the closest space available. All such changes should be initialed, dated, and timed.18 For computerized documentation, the original entry should be preserved electronically as well as the amended one.4 Appropriate correction of documentation errors is a routine part of nursing education. Interestingly, educational instruction in documentation differs significantly between nurses and physicians.
Nursing curriculum devotes countless educational hours, both didactic and clinical, ensuring the understanding of proper documentation and charting rules. The foundation of nursing care is upheld by the nursing process, which influences components of nursing documentation. Nursing process, which is defined as an organizational method of planning and delivering nursing care, provides a basis for complete documentation required by professional nursing standards written by national and state laws, by national nursing organizations such as the Emergency Nurses Association, and by regulatory bodies such as the Joint Commission Accreditation of Health Care Organization (JCAHO).19 These standards, which are considered criteria in defining quality of care, are integrated into hospital policies and procedural guidelines. Practice that fails to meet these standards of care is considered negligent.11
By contrast, documentation is not stressed in medical school curriculums or within the emergency medicine residency core curriculum. Little is known about how documentation is taught and implemented in emergency medicine residencies.20 In one study of emergency medicine resident documentations, Howell and colleagues reported that less than two hours of curriculum is dedicated to documentation.20 This study also reported that emergency medicine residents receive little real-time mentoring from emergency medicine faculty about the quality of their charting, either from a medicolegal or a coding and billing perspective. The primary driver of physicians' documentation has been reimbursement, most often with documentation parameters being placed by outside government agencies. It remains governmental agencies and insurance providers that largely shape the content of physician documentation in emergency medicine.
Regardless of drivers or educational background, the need to clearly communicate through written or electronic documentation is vital. Use of standard symbols and abbreviations reduces the likelihood of misinterpretation by the reader.4
Case #4: Millichamp et al v. Baylor University Medical Center, et al.21
A 40-year-old truck driver was involved in a highway rollover and was taken to Baylor University Medical Center. He was transported on a stabilizing backboard with a cervical collar in place. It was noted that the patient had a hematoma on his head and complained of a burning sensation within his fingers. X-rays of his neck and spine were completed. Shortly thereafter, the ED nurse removed the patient's cervical collar and walked him about 10 feet. During this time, he collapsed and ultimately suffered a severe subluxation of the spinal cord, which left him with no sensation from the chest down and minimal movement in his arms and hands.
During the trial, the ED physician testified that he had not completed his entire examination and had not instructed the nurse to remove the cervical collar or to walk the patient. Contrary to the physician's testimony, the nurse testified that she had been instructed by the physician to remove the patient's cervical collar and to prepare the patient for dismissal. The plaintiffs argued that the ED physician and nurse both failed to treat the patient appropriately based upon the mechanism of injury and presenting complaints. The verdict was for $31.1 million.
Discussion
While verbal instructions are used daily by members of the ED team, caution must be taken with verbal orders. As in the case above, verbal orders may lead to miscommunication and misinterpretation of the intended plan of care. Patient safety can be affected by treatment based upon assumptions that a health care member may make due to nonexistent, confusing, or incomplete communication.17
This case also clearly demonstrates the adage: "if it is not written, it never occurred." There was not a written order for cervical spine clearance in this patient, giving the nurse little upon which to base her argument that she was told to go ahead and remove the collar. However, as previously noted, pointing fingers among providers is futile, serving only to prove to the jury that communication among them was poor. The "he-said, she-said" testimony again emphasizes the importance of written documentation that clarifies the care that was intended and supports the care that was provided.
Verbal orders should be managed according to hospital policies, but as a general rule should be acceptable only under emergency situations when the physician cannot promptly write an order.22 Verbal orders should be signed as soon as the emergency situation is over, thus, converting them to written form.
Case #5: Margarita Rupena et al v. Maryam Pasha, MD and Sheridan Healthcorp, Inc.23
A 48-year-old male was involved in a motor vehicle accident in which he suffered internal injuries that were not immediately apparent at the scene of the accident. The patient initially refused treatment; due to his deteriorating condition, the ambulance was dispatched back to the scene, and he was then transported to the Parkway Medical Center. The ED nurse conducted a primary and secondary assessment. Then, the ED physician was contacted 30 minutes after the patient's arrival. The patient suffered a cardiac arrest within 13 minutes of the ED physician's arrival.
At trial, the ED physician argued that she lost valuable time in treating the patient due to the delay in contact by the nurse. Although the patient's refusal for treatment complicated the timeliness of treatment, the plaintiff's attorney claimed that the information the physician received regarding the mechanism of injury and vital signs should have alerted her to the potential for internal bleeding, and that her assessment should have been more timely. The jury returned a verdict for the defense.
Discussion
While communication among ED providers—whether written or verbal—needs to be clearly understandable and well documented, it also needs to be timely. Timely communication continues to be a major factor influencing patient safety.17 Delays in appropriate treatment as a result of poor or incomplete communication often can lead to unnecessary morbidity or even patient death.1
Reflected in nursing trauma core courses, a primary assessment is foremost when caring for trauma patients. In patients with potentially severe injury, primary assessment should be completed simultaneously with the physician. Nurses should document the exact time of physician notification, reason for notification, and whether subsequent orders were given.16 Documenting time of physician arrival is also of value. While nurses need to be timely in their notifications, so too must physicians be timely in their responsiveness, quickly reacting to nurses' reports regarding patient status. The physician should document the time that he/she initiated a patient evaluation as well as time for any major actions taken. Documentation of times provides a storyline for the patient's evaluation in the ED. Times should help demonstrate the excellent care provided and not be used as weapons in "chart wars," which pit providers against one another in a paper trail exemplifying poor communication.24 The tragic case above illustrates that the value of timely communication cannot be underestimated.
The Need to Reconcile…Differences in Assessment by RN and MD
Case #6: Anonymous 41-year-old Male v. Anonymous Physician25
A 41-year-old male presented to an ED complaining of a "strange sensation" of dizziness, weakness, numbness, and left-sided headache shortly after taking a Cepastat lozenge. At presentation, all of these symptoms had resolved; at that time the physician noted in his documentation of the neurologic examination "good motor strength/sensory okay." No imaging studies or consultations were ordered, and the patient was discharged with the diagnosis of "adverse medication reaction/hypotension." The patient was transported back to the ED that evening. Nursing notes described the presence of uneven pupils and facial droop. A head CT scan and neurological examination on the second visit revealed the diagnosis of an acute cerebrovascular accident. The patient's status continued to deteriorate, and he subsequently died 17 days later.
The family brought suit. The plaintiff's attorney claimed that a thorough neurological examination was neither completed nor documented by the physician during the patient's initial visit to the ED. The physician was accused of not ruling out an evolving stroke. The case was settled for $1.25 million.
Discussion
Frequently iterated in articles emphasizing the value of medical documentation is the fact that the ED record provides legal proof of the care a patient receives. In reality, documentation of care has become synonymous with the care itself, and failure to document implies failure to provide care.26 Failure to adequately document on the part of the physician can be compounded by the presence of discrepant or conflicting information elsewhere within the record, particularly in the nurse's notes. The case above illustrates both.
Although it is well known that transient ischemic attack (TIA) symptoms can wax and wane, and that on presentation this patient's symptoms had resolved, documenting only "good motor strength/ sensory okay" for the entire neurological examination is completely inadequate. Sloppy or cursory documentation can be interpreted by a jury as sloppy or cursory care, whereas meticulous charting points to careful treatment.7 Documentation of the examination should be most detailed for the organ system related to the presenting complaint (e.g., in this case the neurological examination for a patient presenting with TIA symptoms.)
The lack of a thorough neurological examination on the first visit became a point of emphasis in this case, as the patient returned to the ED within hours, and nurses' notes immediately commented on neurological abnormalities. Certainly, it would have been even more damaging if the nursing documentation noting abnormalities had been from the initial visit. The plaintiff's attorneys focused on these discrepancies to raise doubts about the quality of care provided, reliability of the documentation, and the thoroughness of the defending physician.
Case #7: The Estate of Gresham v. Central Virginia Emergency Associates and Henry27
Christopher Gresham was a 19-year-old male with a history of asthma who was transferred by ambulance to Richmond Community Hospital for sudden onset of dyspnea and epigastric/chest pain shortly after eating with his family. Nursing triage assessment revealed dyspnea, shallow respirations, and significant hypoxia but "no wheezing" on auscultation. Dr. Brian Henry was the attending emergency physician who evaluated Mr. Gresham. He chose a templated chart entitled "wheezing/asthma", although several other templates for dyspneic patients were available. In two separate places in the record, Dr. Henry noted presence of wheezing, and he diagnosed "status asthmaticus." Mr. Gresham continued to decline, dying in the ED three hours after presentation.
Suit was filed alleging failure of adequate treatment of asthma, including failure of timely intubation. The defense argued that Mr. Gresham had died of pulmonary embolism and not from asthma. The defense stated that Dr. Henry recorded findings and the diagnosis of asthma to ensure hospital admission. The jury returned a $1.5 million verdict for the plaintiff.
Discussion
As highlighted in the opening cases of this article, careful review of the nursing notes is essential, both for clinical patient care and medicolegal purposes. Nurses' notes are often the first notes reviewed by a legal team.24 Often they are the most legible entries, provide a more reliable time course of events in the ED, and often are the source of entries that contradict what the clinician has documented.24 When conflicting information is recorded, it is difficult to negotiate professional credibility in court.18
In the case above, the triage nurse noted "no wheezing" on her examination, but Dr. Henry twice noted the presence of wheezing in the patient's record. Dr. Henry would have been much better had he acknowledged this difference in real time in his documentation. A simple "nursing notes reviewed, wheezing present at the time of my exam" would have taken away the questions that remain by absence of such documentation: Was the nursing assessment noted incorrect, potentially serving as a signed post for an alternative cause of dyspnea such as pulmonary embolism? Was the patient's asthma so severe that no wheezing was explainable by the near complete lack of air exchange? Did the patient's condition change between the nurse's triage examination and Dr. Henry's? Speculation could be extinguished by acknowledgment of nursing findings by Dr. Henry. Differences in assessed opinion are not inherently bad if they are addressed in real time in the chart.28 Resolving discrepancies in real time requires foresight and takes time, but can make the difference between a successful suit for the plaintiff and one not filed.7
Case #8: Rowe v. Sisters of Pallottine Missionary Society29
Brian Rowe was a 17-year-old male who sustained a left knee injury when he lost control of his motorcycle and it landed on his left leg. He was transferred by ambulance to an ED where he complained of severe knee pain and left foot numbness. Nurses did not find any pulse distal to his knee, even with the aid of a portable Doppler ultrasound device. Dr. Willard Daniels was the attending emergency physician who evaluated Mr. Rowe. He had difficulty finding — but claimed and documented that he did find — distal pulses both in the foot and leg. Radiographs revealed intra-articular bony fragments, but Dr. Daniels' diagnosis was severe knee strain, and he dismissed the patient home. The patient went to a different ED the next day and was found to have a knee dislocation, lacerated popliteal artery, and a compartment syndrome. The patient was hospitalized for 35 days and underwent multiple procedures that saved his leg, but his disability was severe.
Suit was filed against Dr. Daniels and the hospital. Dr. Daniels settled for $275,000. At the trial, the plaintiff contended that the nurse had not followed hospital policies in her failure to advocate the patient up the chain of command when she "believed that appropriate care was not being administered to the patient by the physician." The court also held the hospital accountable for negligence of the nurses, awarding the plaintiff an additional $880,000 from the hospital.
Discussion
While there are several alarming aspects of this case from a legal perspective, it again serves as an example of where nursing notes ("no pulse") and physician notes ("distal pulse is present") are in conflict. Pertinent observations can be made by the nurse based upon the time that he/she spends with the patient. There may be observations that were not apparent during the physician's initial examination.2 From a clinical perspective, this case illustrates how attentiveness to the nursing assessment may possibley prevent the physician from overlooking a catastrophic diagnosis. Clearly, the ultimate diagnosis and outcome of this case confirmed that the nursing assessment was on target, and neither acknowledged, acted upon, or reconciled by the physician. The need for active review of nursing notes remains.
This case also raises the issue of vicarious liability. Vicarious liability is the accountability of one individual for the actions of another. Vicarious liability is reviewed in detail in a prior issue of the ED Legal Letter by Moore.28 Under vicarious liability, both physicians and hospital can be held liable for the actions of their nurses. Physician accountability for the action of nurses rather than for the documentation of nurses will be addressed in a later section.
Case #9: Duckworth v. DCH Regional Medical Center30
Mr. Duckworth was an 83-year-old male visiting his wife in the DCH Regional Medical Center intensive care unit. At approximately 10:24 pm as Mr. Duckworth was entering an ascending escalator, he lost his balance and fell backwards, landing directly on his head. He presented to the ED immediately after the accident, where the triage nurse classified his acuity as nonemergent and then visually observed the patient in the ED waiting room for the next two hours. At 2:00 am, he suddenly vomited and was taken back to a patient care room where an MRI scan was ordered. The MRI scan revealed an expanding intracranial bleed; by 4:00 am the patient was in surgery. The patient died 13 days later.
The family filed suit. The plaintiff's attorneys argued that there was failure to complete a limited, precursory nursing assessment and that he did not receive a precursory medical examination for four hours after presentation, in which time an obvious head injury should have been diagnosed with immediate intervention. The jury awarded the decedent's estate $350,000.
Discussion
While the previous two cases illustrated differences in nurse and physician assessment, this case brings into question the quality and timeliness of assessment. The emergency physician of record has a legal duty to any patient who presents to the ED for care even if he/she is still in the waiting area and has had only a triage evaluation by a nurse. The triage evaluation becomes an integral piece in the care puzzle, particularly as ED volumes increase and EDs face overcrowding. Delays and bottlenecks that prolong time to first physician evaluation place the patient at risk clinically and the physician-of-record at risk legally.
Triage nurses must prioritize patients based upon data that they gather during the triage assessment. Triage nurses also are challenged to sort and re-assess patients as they wait, reprioritizing if necessary. A systematic nursing assessment is a core nursing responsibility, yet it is commonly absent or incomplete within the medical record.31 In this elderly patient with a head injury due to a fall of uncertain etiology, a systematic assessment would have helped detect why he was assigned a nonemergent acuity. A nursing assessment is useless unless documented as well as verbally communicated to the physician or provider based upon changes in a patient's condition.2
In this case, an initial nursing assessment was completed; although the patient was "observed" in the waiting room for two hours, no reassessment was documented. There was significant delay between presentation and rooming with physician assessment, and imaging occurred nearly four hours after his fall and presentation. Lack of nursing reassessment and delay to physician assessment were focal points of this case and are a frightening reality in many EDs today.
Systems changes must be enacted to decrease waiting room time and reduce time to physician evaluations. Appropriate triage assessments and reassessments are imperative in the prevention of poor patient outcomes due to unrecognized deterioration. Nurses must be accountable in identifying status changes that may negatively affect patient outcome. Standards of care must be implemented based upon patient assessments to ensure timely patient care.1 Practice that falls below the accepted standard of care would be defined as negligence.
Relationships Established by Documentation… the MD as "Captain of the Ship"
All the preceding cases have highlighted the value of nursing documentation, emphasizing the importance of careful review and acknowledgment, reaction, and proper reconciliation of the same by the emergency physician. These actions are critical to optimizing patient care, but also serve to demonstrate the accountability the physician has for the practice of those under his or her direction. While documentation discrepancies expose a physician to malpractice risk, so do the actions of registered nurses and midlevel providers (e.g., nurse practitioners) with whom he or she works. The case below will illustrate this type of risk known as vicarious liability.
Case #10: Quirtk v. Zuckerman32
John Quirtk presented to the Whinthrop University Hospital ED the morning after crushing his right forearm in the folding extensions of a falling A-frame ladder. The triage nurse evaluated his arm noting "areas swollen" and placed him in the ED fast track. He was seen by a nurse practitioner who ordered plain films, which were negative. She placed him in a sling, provided oral narcotic-analgesics, and told him to follow up with orthopedics for "epicondylitis." The attending emergency physician, Dr. David Zuckerman, reviewed the case with the nurse practitioner, signed the record and the prescription, but never saw the patient. The next day, Mr. Quirtk returned to the ED and was diagnosed with compartment syndrome. After multiple surgeries, he ultimately had to have his arm amputated. He filed suit against the hospital, the nurse practitioner, and Dr. Zuckerman. The verdict was for the plaintiff. Award amount is unknown.
Discussion
Vicarious liability is the theory by which a court holds the party legally responsible for the negligence of another, not because that party did anything wrong but because of the relationship to the wrong-doer.28 Vicarious liability is based upon the premise of respondeat superior – "the boss answers." This premise provides a structure of accountability allowing someone who is wronged to obtain reparation. It is the legal premise by which an employer (e.g., hospital) is responsible for the actions of employees (e.g., nurses, technicians, and sometimes physicians).
The case above demonstrates vicarious liability on many levels. Dr. Zuckerman was directly supervising the case of the nurse practitioner who provided care to Mr. Quirtk; he was the defined leader in a specific environment or so-called "captain of the ship." By this doctrine, courts have routinely identified the most superior person in attendance when care is being administered as the party most responsible to ensure the safety of the patient and to adhere to the standard of care.33 Under this doctrine, emergency physicians like Dr. Zuckerman can be held accountable when they have direct control of the actions of residents, midlevel providers, and nurses under their supervision.
What about the triage decision of the nurse to place Mr. Quirtk in the fast track area of the ED? Is the hospital, Dr. Zuckerman, or both responsible for the actions of the nurse? Hospitals are generally responsible for the actions of nurses because of the employer-employee relationship and respond based upon the superior doctrine. The borrowed servant doctrine, dating to time when the farmers were responsible for the actions of their borrowed servants, is a form of archaic liability whereby a physician is accountable for the actions of the hospital employed nurse "borrowed" by the physician to do work in the hospital.28
In instances like the case above where the actions of a nurse (triage) are not directly under the control of the physician and are made independently without the physician's knowledge, it would be unlikely for the court to hold a physician responsible. The hospital, as employer, is more likely to be held responsible.28
Beyond the clinical importance of the ED record and its value as a legal document, the emergency physician must consider the legal relationships established with nurses and other providers represented on the record. Through these relationships, the emergency physician is exposed to vicarious liability. Courts, however, are realizing that medicine is becoming increasingly complex and even as "captain of the ship," the physician is seldom the sole person in charge.
Summary
Excellence in medical documentation reflects excellence in medical care.34 At its best, the medical record forms a clear, complete, legible detailing of care delivered, credits competent care, and forms a tight defense against allegations of malpractice.34 Emergency physicians must understand the value of nurses' notes within the medical record both from a clinical and a liability perspective. To avoid liability and ensure safe patient care, emergency physicians need to review nurses' notes, react in timely fashion to nurses' assessments, and reconcile any discrepancies in assessment in real time.
Emergency physicians and nurses work closely as a team. The teamwork needs to be reflected in documentation that supports and confirms the care provided and demonstrates excellent communication between nurses and physicians.
|
|
Acknowledgement: The authors would like to acknowledge Cindy Franke for her patience, persistence, and tireless efforts in preparation of this article.
References
1. Meiner SE. Nursing Documentation. Legal Focus Across Practice Settings. Sage Publications, Inc., Thousand Oaks, CA, 1999.
2. Beckmann, JP. Nursing Negligence. Analyzing Malpractice in the Hospital Setting. Sage Publications, Inc., Thousand Oaks, CA, 1996.
3. Alford DM. The clinical record: Recognizing its value in litigation. Geriatr Nurs 2003; 24:228-230.
4. Weaver JC. Appropriate documentation: Your first (and best) defense. ED Legal Letter 2004;15(5):49-60.
5. Powell Administrator v. Oeters and Beaufort Emergency Medical Associates, Beaufort County (NC) Superior Court, Case No. 03CVS785. Medical Malpractice Verdicts, Settlements and Experts 2005; 21(4):14.
6. Fiesta J. 20 Legal Pitfalls for Nurses to Avoid. Delmar Publishers Inc., Albany, NY, Chapter 19, pages 168-175, 1994.
7. Stephens E. Medical-Legal Liability in Emergency Medicine. Updated 8-8-05. Available at: www.emedicine.com/emerg/topic945.htm
8. Davidson SJ, Zwemer FL Jr, Nathanson LA, et al. Where's the beef? The promise and the reality of clinical documentation. Acad Emerg Med 2004; 11(11):1127-1134.
9. Langowski C. The times they are a changing: Effects of online nursing documentation systems. Q Manage Health Care 2005;14(2):121-125.
10. Daisy Love v. Rancocas Hospital, et al., Civil Action No. 01-5456. Westlaw 374 F.Supp.2d 425, 2005.
11. Helm A. Nursing Malpractice. Sidestepping Legal Minefields. Lippincott Williams & Wilkins, Philadelphia, PA, 2003.
12. Anonymous. Elements of Medical Malpractice. Accessed: 10/11/2005. Available at: www.medi-smart.com/elements.htm
13. Eggland ET, Heinemann DS. Nursing Documentation. Charting, Recording, and Reporting. J.B. Lippincott Company, Philadelphia, PA, Chapter 7, pages 137-162, 1994.
14. Teytelman Y. Effective nursing documentation and communication. SONCN 2002;18(2):121-127.
15. Anonymous v. Anonymous Triage Nurse, Anonymous Emergency Room Physician, unknown Massachusetts venue. Medical Malpractice Verdicts, Settlements & Experts 2000; 16(9):12-13.
16. Miller J, Glusko J. Standing up to the scrutiny of medical malpractice. Nurs Manage 2003; 34(10):20-22, 80.
17. Krasker GD, Lin DM. The JCAHO 2005 National Patient Safety Goals. Successful Strategies for Compliance. HCPro, Inc., Marblehead, MA, Chapter 2, pages 21-53, 2004.
18. Wood C. The importance of good record-keeping for nurses. Nursing Times 2002; 99(2):26-27.
19. White L. Documentation and the Nursing Practice. Thomson – Delmar Learning, Clifton Park, NY, 2003.
20. Howell J, Chisholm C, Clark A, et al. Emergency medicine resident documentation: Results of the 1999 American Board of Emergency Medicine in-training examination survey. Acad Emerg Med 2000; 7(10):1135-1138.
21. John Edward Millichamp III, individually and on behalf of Brandon Millichamp, a minor, and Carol Elizabeth Millichamp, individually v. David J. Mendelson, MD, Anthony C. Toppins MD, and Baylor University Medical Center, Dallas County (TX) District Court, Case No. 01-1793-E. Medical Malpractice Verdicts, Settlements and Experts 2004; 20(4):20.
22. Nurse's Legal Handbook, 5th Edition. Lippincott Williams & Wilkins, Philadelphia, PA, Chapter 7, pages 232-254, 2004.
23. Margarita Rupena, as PR of the Estate of Danilo Rupena, and as mother and next best friend of Josip Rupena, Danica Rupena, Jasika Rupena, and Danilo Andre Rupena v. Maryam Pasha, MD and Sheridan Healthcorp, Inc., Dade County (FL) Circuit Court Case No. 01-00468 CA 05. Medical Malpractice Verdicts, Settlements and Experts 2004; 20(5):18.
24. Correia NG. Adverse events: Reducing the risk of litigation. Cleveland Clinic Journal of Medicine 2002; 69(1):15-24.
25. Anonymous Forty-One Year-Old Male v. Anonymous Physician, Middlesex County (MA) Superior Court. Medical Malpractice Verdicts, Settlements and Experts 2005; 21(6):13.
26. Anonymous. Looking at the nso risk advisor in another light. Legal significance of the medical record. AccessedL 10/11/2005. Available at: www.nso.com/newsletters/newsletters.php
27. Administrators of the Estate of Christopher Gresham v. Central Virginia Emergency Associates, LLC and Henry, Henrico County (VA) Circuit Court. Medical Malpractice Verdicts, Settlements & Experts 2004; 20(5):16.
28. Moore GP. Determining liability in the ED: Who takes the blame? ED Legal Letter 2005; 16(3):25-36.
29. Rowe v. Sisters of Pallottine Missionary Society, 201WL 1585453 S.E.2d – WV. Nursing Law Case of the Month, 2005.
30. Duckworth v. DCH Regional Medical Center, Tuscaloosa County (AL) Circuit Court, Case No. 00-0477. Medical Malpractice Verdicts, Settlements & Experts 2003;19(2):14.
31. Beckmann, JP. Nursing Malpractice. Implications for Clinical Practice and Nursing Education. University of Washington Press, United States, 1995.
32. John Quirtk Jr. and Celina Quirtk v. David Zuckerman, Doris Korona and Whinthrop University Hospital. Westlaw 2005; 196 Misc.2d 496, 765 N.Y.S.2d 440.
33. Ott CJ, Hourny DE. Medical malpractice and the emergency medicine resident. Ann Emerg Med 2000; 36(6):631-633.
34. Teichman PG. Documentation tips for reducing malpractice risk. March 2000; Accessed: 10/11/2005 Available at: www.aafp.org/fpm.xml
Ever present in the health care provider's training and practice is the continual responsibility to provide documentation. Although it is ever drummed into our heads that proper documentation is necessary for the purposes of billing, quality assurance, and risk management, documentation is also important in real time for the purposes of communication among caregivers. Not only must each health care practitioner record his/her own activities and findings related to a patient's care, but each practitioner also must take heed of every other provider's documentation.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.