Tuesday, November 16, 2010

Will Your Note Hold Up in Court?

One of the details of my daily routine is to read over nurses' documentation. Many times as I read notes, so much information is missing, and I cannot help but think, "Would this nurse remember this conversation a year from now, and how would she prove she gave accurate and complete advice?"
Let's look at what an accurate note consists of. The easiest way to remember what to include in an accurate note is to put it this way:
Analytical: The difference between telephone triage assessment and assessing a patient face to face is that you cannot visualize the patient. Your listening skills must be sharp, and you not only are you listening to what the caller is telling you, but you are also listening for sounds that helps with your assessment of the patient. These might include a cough, breathing, crying, anxiety, pain, and fear. Taking into account all of these things, the nurse must determine an accurate assessment.
Concise: Every note must be as brief as possible, but must include every pertinent detail of the call including symptoms, measurements, complaints and/or concerns.
Chronological: While painting the complete picture of the problem at hand, it is best that the events be given in chronological order from when the symptoms started until the time of the call to the triage nurse.
Unambiguous: The note must give clear details of the call. It is best to answer the 5 W's to avoid leaving out any details. These include what, when, where, why, how and to what extent.
Risk-Focused: No one wants to think that they might sometime be a party to a law suit, but realistically, at some point, that could be a very real possibility. Therefore, you must document defensively. Make sure that all documentation includes a complete assessment, and if possible include the patient's own words. Do not be judgmental, but give facts. When giving advice, adhere strictly with the protocol, and thoroughly document any advice given that is beyond what the protocol states. Contact with physicians should be documented and any new orders received should be documented as well.
Accountability: Not only are nurses accountable for their actions, but some accountability falls on the patient or caregiver as well. It is important to document that they understand instructions given and their intent to comply. If they choose not to comply, then the note should reflect documentation of such, and that they were advised of any risks of not complying. If the nurse feels the patient's life could be compromised by not complying, then the nurse should notify the physician on call.
Timely: The nurse is accountable to give timely advice and/or instructions. If the call is determined to be life threatening in nature, the call should cease with the nurse instructing the caller to call 911 for further assistance. Every second counts, and the nurse should follow-up within a few minutes to be sure the patient is receiving the life saving assistance they are entitled to.
Explanation: The caller deserves an explanation of why they are being given the advice or instructions that they have received from the nurse. They are much more likely to comply if they understand why, and they will be reassured that they are being given knowledgeable advice. In return, the caller will be pleased, and will be less likely to call back for reassurance.

Telephone triage nursing is so different than bedside nursing, because the senses of touch, sight, and smell cannot be used. This means that listening skills have to be so much sharper, and in return requires quick thinking and decision skills by the nurse.