Avoiding charting inconsistencies in medical documentation can help nurse practitioners protect themselves from negative legal implications. Many APRNs are fearful of being involved in a malpractice case or having legal actions taken against them.
Nurse practitioners are not immune to a malpractice suit. Sometimes we are just in the wrong place at the wrong time. Sometimes there is a zebra (rare case or presentation) when we are used to seeing horses. Sometimes there is a difficult patient that would file a lawsuit no matter who the provider was.
Nurse practitioners document a patient encounter for 3 main reasons and avoiding negative legal issues is an important one! Nurse practitioners can work to avoid charting inconsistencies to better protect themselves from a negative outcome on a malpractice lawsuit.
*Full disclosure, I am not a lawyer and these tips are for informational purposes only. Nurse practitioners should seek practice specific advice from a lawyer.
Charting inconsistencies within the chart note.
One of the common inconsistencies I see involves the history of present illness and the rest of the chart note. I see a lot of nurse practitioners write out a lengthy history of present illness with lots of additional information. This added info may actually negatively affect the NP in a malpractice case.
For example, if a nurse practitioner mentions a patient had abdominal pain during a chronic medical visit, and the medically necessary exam and proper diagnostic tests are not completed, the nurse practitioner looks negligent. If the patient did develop a serious medical condition related to abdominal pain, the nurse practitioner would be held irresponsible for not further investigating.
Nurse practitioners need to make sure what is mentioned in the history of present illness gets addressed during the physical exam, assessment, and plan. This is why The Nurse Practitioners Charting School recommends problem focused visits. Problem focused notes helps to avoid charting inconsistencies and protect NPs legally.
These charting tips can help nurse practitioners protect themselves. Check out this article by The Elite Nurse Practitioner titled: Be careful with what you put in your HPI.
Another example is inconsistent information in the history of present illness and review of systems (ROS). If you mentioned the patient experiences shortness of breath in the HPI but mentioned “denies shortness of breath” in the ROS, which one is correct? A malpractice lawyer can easily pick apart the patient’s chart with these types of charting inconsistencies.
Charting inconsistencies between healthcare workers.
While registered nurses, licensed practical nurses, and medical assistants have their own licenses, nurse practitioners are ultimately responsible for the patient. Nurse practitioners have a higher level of training and because of this, our roles and responsibilities are greater.
When the APRN signs the chart note they are responsible for all information. Even if the nurse/medical assistant completed a home medication review, past medical history, or input vital signs, the NP is ultimately responsible. If the information is incorrect, it will fall back on the nurse practitioner. We will look at a few examples of charting inconsistencies between healthcare workers and charting tips to protect ourselves as NPs.
Home med reconciliation.
One of my biggest pet peeves is an incorrect home medication reconciliation (who’s with me on this one!). It is very frustrating to properly diagnose and treat the patient if you do not have all the information. Think about a patient who comes in with symptomatic bradycardia and you do not know they are taking a beta blocker. How does this change the treatment plan?
Or if there is a patient with an elevated A1C and you don’t know what current diabetic medications they are taking. How do you know what class of medication to start? How are you supposed to assess for medication interactions if the home medication list is inconsistent?
Many nurses/medical assistants are responsible for completing the home med rec. Taking time to educate the nurses/MAs the importance of an accurate home med rec and how to complete one can make a significant difference in a malpractice case. Remember, the NP is ultimately responsible for the patient. So it may be beneficial to confirm with the patient what meds (OTC and supplements as well!) they are taking.
Past medical history.
Similar to home med recs, most nurses/MAs are responsible for inputting past medical history. If a patient comes in for abdominal pain, it is vital (pun intended) to know what past surgeries the patient had. If you are seeing an annual wellness exam, there are certain cancer screening tests that are recommended. The medical record should have the correct information so a screening test is not duplicated (or worse not ordered/completed at all). As the nurse practitioner you need to know this past medical history in order to properly care for the patient.
Another inconsistency in a patient’s chart may be vital signs. How many times was a heart rate incorrectly typed into the charting system? 85 beats/min is a lot different than 185 beats per minute! Or what if the oxygen saturation was documented as 55% instead of 95%. Or the nurse forgot to chart on 2L nasal cannula instead of room air like they are used to charting on patients.
If there is a medical malpractice case, the plaintiff lawyer is going to tear apart these inconsistencies in the chart note. Remember, the nurse practitioner will be held responsible for the incorrect information. An error of documented vital signs can make or break a malpractice case. Nurse practitioner should avoid charting inconsistencies to protect themselves from legal issues.
There are often inconsistencies in the physical exam of a patient that can create a lot of issues during a malpractice case. For example, if the nurse measured and described a wound to the left lower extremity and you documented the right lower extremity, which one is correct?
If the nurse documented crackles in the bases of the lungs and you documented clear breath sounds, it won’t look great when the patient develops a respiratory complication and you had incorrectly documented the assessment.
Another example is if the nurse documented no circulation, motor, sensory assessment due to a below the knee amputation. However, you charted that cap refill was less than 3 seconds, skin pink, dry, warm to touch, patient able to move toes, and sensation intact, this is a major charting inconsistency.
These examples of small, conflicting information can make or break a malpractice case. It is worth the little extra time to review your documentation and avoid charting inconsistencies to better protect yourself as the nurse practitioner.
Charting inconsistencies of spelling and grammar.
I have seen a lot of nurse practitioners struggle with perfectionism and spend too much time writing the perfect chart note. I’m not saying nurse practitioners need to spend 20 minutes ensuring a note is perfect, but I do recommend creating a professional chart note. A quick review for spelling, grammar, and accuracy of information can make a tremendous impact.
A chart note with these small inconsistencies can look unprofessional. A sloppy chart note can look like the healthcare provider is sloppy. If a nurse practitioner is involved in a malpractice case, they do not want to look like a careless provider. It is best for nurse practitioners to avoid charting inconsistencies and protect themselves legally.
Again, a lot of nurse practitioners can spend too much time perfecting their chart note (click here for more time management and charting tips so you can STOP charting at home), but if they take a few minutes to run through spell check or quickly look over the chart note, it may help them in a malpractice case.
Nurse practitioners can avoid charting inconsistencies and help to protect themselves legally. It is important for NPs to be well informed and motivated to improve their documentation. For other tips check out The Legal Issues with Charting Course offered by The NP Charting School.
The course teaches NPs how to prevent a malpractice suit and put their mind at ease regarding the legal issues of charting. There is also a special presentation by a legal nurse consultant giving her insight and tips to avoid malpractice cases! Click here to learn more about the course!