Documentation errors are easy to avoid and correct
Don’t obscure errors; include all dates and times
One procedure is finished. The surgeon is ready for the next patient. Turnover time is critical. Everyone moves quickly from one area to the next. What about your documentation?
It’s one thing to keep everything moving swiftly throughout the same-day surgery process, but don’t let the quick pace affect the completeness or accuracy of your documentation, says Anne M. Roy, RN, JD, regional operations manager of Health Inventures, a health care consulting firm in Westminster, MA.
"I’m finding that most documentation errors are simply mistakes made when shortcuts are taken to save time," she says. To ensure that sloppy or inaccurate documentation doesn’t cause a problem in patient care or in a liability claim, Roy suggests four areas that require your attention:
• Use approved abbreviations. "Don’t make up your own abbreviations," emphasizes Roy. Every outpatient surgery program should have an approved list of abbreviations for documentation purposes that every nurse can access easily, she suggests. "If there is no abbreviation listed for the word you want to use, spell it out completely," Roy adds.
• Date entries. "People don’t date entries," says Roy. Even if a month and day are used, the year often is left off the entry, she adds. "It’s important to keep the year in the documentation, because legal issues can occur years after the procedure," Roy points out. Each time the chart moves to another department or another staff member, the entry should have the full date and time on it, she adds.
• Don’t hide errors. Don’t ever scratch out an entry to the point you can’t read what’s written, says Roy. "If you make an error, draw a line through the error, then write on the next line," she says. "Make it obvious that you’re not trying to obscure something by starting the entry with the phrase correction to entry above.’"
When you do draw a line through an entry, be sure to put your initials, as well as the date and time, she adds. Also, ban any type of correction fluid designed to cover up ink, says Roy. Although errors happen, and you need to correct them, you should never obscure any information, she adds.
• Insert late entries appropriately. "If you forget to enter something and go back to the chart later, after other entries have been made, don’t try to squeeze the entry between lines of information just so everything will be chronological," says Roy. "Just start the entry with the phrase late entry’ and write the information along with the date and time of the entry," she explains.
The latest you ever should add information would be the next business day, Roy adds. After that point, the accuracy of your memory or the information could be called into question, she says.
Also, never sign documentation for someone else, Roy emphasizes. "This doesn’t happen often, but I’ve seen cases of nurses leaving work, then calling back to a friend to ask them to add some information to the chart," she says.
Although it is not a frequent occurrence, Roy says that it is alarming because it can place the second nurse in a precarious position. "If you do have to add information to a chart for someone else, be sure to start the entry with the statement that you received a call from the nurse who asked you to add the missing information," she suggests.
As more same-day surgery programs look at computerized documentation, there are issues to keep in mind, says Roy. Computerized documentation can ensure a complete record because the system prompts nurses to add missing information as they chart, she says. Also, there are no legibility problems with a computerized record, Roy adds.
These were among the reasons the outpatient surgery staff at Trinity Medical Center in Moline, IL, switched to computerized documentation when a new same-day surgery facility was opened, says Patti A. Berens, RN, nurse manager for Trinity’s recovery care unit. "Not only did the computerized documentation improve accuracy, but having the record on-line also means that the chart is always available," she says.
The software used by Trinity is manufactured by Meditech in Westwood, MA, and does not delete information if an error is made, Berens says. A notation that an error in documentation was made along with the date and time of the correction as well as the reason for the initial error is entered, she explains.
"I also recommend that only certain people be able to correct documentation entries," Roy says. This gives managers and supervisors an opportunity to double-check information and make sure errors are corrected properly, she adds.
With a computerized record, it is important that every nurse have his or her own identification name, code or number, and password, suggests Berens. "We also tell nurses to be sure to close out the chart completely when they are finished with their documentation so that no one can accidentally document on their patient’s record," she adds.
Some electronic medical records allow access and entry by two or more people at the same time, sources warn. That access can result in duplicate entries of data. One entry can override the other, and only one entry is made instead of two, or no entries are filed to the record, sources say.
Another danger of a computerized system is the tendency to include more information in the documentation than is needed, says Roy. "Some computerized forms that I’ve seen are 50 pages long," she says. "Take a look at the forms you use, and identify the redundant or unnecessary information to eliminate. Ask your medical records personnel, especially a registered record administrator, as well as your risk management director, to advise you as to the information that is needed," she recommends.
One of the most important facets of accurate documentation is to document as you go, says Roy. "The only way to make sure another nurse knows exactly what is going on with your patient if you go on break or transfer the patient from the OR to recovery is to write it all down when it happens," she explains.
Complete information is especially important with medications related to nausea or pain, Roy adds. "Don’t just write down that you gave the patient 50 mg of meperidine, Also, document whether or not the medication worked." This step prevents the following nurse from repeating the same dose and medication if it didn’t work the first time, she explains.
Berens points out an extra benefit to computerizing documentation: "Not only is our documentation more accurate, but our patients appreciate the fact that they don’t have to keep repeating information as they move through the same-day surgery program," she says. "With the information on-line and readily available to each department, staff members can just verify the information instead of asking patients to repeat it for their records."
Sources
For more information on documentation, contact:
• Anne M. Roy, RN, JD, Regional Operations Manager, Health Inventures, P.O. Box 749, Westminster, MA 01473. Telephone: (978) 874-7901. E-mail: aroy@healthinventures.com.
• Patti A. Berens, RN, Nurse Manager of Recovery Care Center, Trinity Medical Center, 501 10th Ave., Moline, IL 61265. Telephone: (309) 779-2257. E-mail: berensp@trinityqc.com.