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Avoiding Malpractice: The pitfalls of electronic documentation.

Throughout Nevada and across the nation, more and more facilities are changing from paper charting to electronic documentation. For the medical records department, electronic entries can make a facility's documents much easier to manage. Some nurses have welcomed the change and actually prefer to chart with a computer. Other nurses are struggling with this change; probably more than administration is aware of.

It is important to remember that for many years, bedside nursing did not require any computer skills. Not too long ago, we were just being trained on how to access the computer to check our patient's lab results for the first time. Prior to that, we had to wait until we received them from the lab in the morning. The average age of our nurses is over forty years old. Many of them have been in nursing for twenty or thirty years. Learning how to use a computer was never a priority in nursing ... until now!

Believe it or not, there are countless nurses out there who are not comfortable with having to document everything on a computer. Even when nurses are used to working with a computer at home, they resist changing the way they document their assessments, medication administration and progress notes at work.

There are many reasons why nurses have been resistant to the changes around them. The most obvious reason is that nurses have been hand-writing everything at work for years, or even decades. Throughout the day, every little thing was to be written down. Even the most skilled computer geek could experience difficulty when trying to change such an ingrained routine. Having to stop what you are doing, go to the computer, possibly wait for your turn to access to the computer, logging in, finding the right patient, finding the right screen, making your entry, and logging out, can seem overwhelming of a process when you used to just simply write it down.

However, if you think about it, it was not really that long ago that nurses and nursing assistants had to start documenting every little thing at all. I am sure that most of you will remember when the "checklist" first arrived on the scene and how much resistance there was to having to complete your assessment using a pre-printed form by filling in the blanks or checking the boxes.

The most difficult part of implementing any type of change is not the physical change itself; it is the psychology behind having to make a change that causes such great hesitancy. When people are faced with a change that is mandated by the powers that be, there is always some resistance. People tend to doubt themselves, fearing that they will not be successful, feeling inadequate, and many people have the limiting belief, "I just can't do that!" It is actually a person's psychology that creates the biggest barrier to change, not the change itself. We all tend to steer away from pain and move towards pleasure. In this case, the pain we steer from is the fear of the unknown and the pleasure we seek is doing what we know.

Unfortunately, when trainers are faced with the task of teaching employees a new skill, such as documenting on a computer, the psychology of change is rarely addressed and the consequence is the majority will have a difficult time converting to the new way of doing things. Some will never truly embrace the change and will continue to struggle, telling themselves, "I can't do this," as though it were a fact, just the way it is, the way it will always be.

The reality is there are nurses out there who are being fired for not catching on to the new way of documenting. Some nurses have claimed that after being at a new facility for only a few weeks, they have been let go for being inefficient on the computer or failing to document on time, document enough, or document at all.

There are other nurses who have been resisting the changes around them for months or even years. They have managed to stay just under the radar for so long that their bad habits have become their new norm and they begin to believe that their approach must be acceptable since there have been no real consequences yet. Even though they have been counseled before and continue to fail to meet compliance requirements, they just cannot seem to fully commit to documenting everything on the computer.

The most dangerous area of documentation is narcotic administration. When nurses fail to accurately document when they give pain pills to a patient or waste narcotics, they are setting themselves up for trouble. Nurses who struggle with computer documentation also have difficulty with accurately documenting their medication administration.

Charge nurses are particularly at risk in this area. Since many charge nurses do not have assigned patients of their own, they do not chart as routinely as the floor nurses do. However, charge nurses rarely go through the day without any patient contact. In fact, many charge nurses help take care of more patients than they realize and their interactions with patients are rarely ever charted; especially now that computers have hit the scene.

One of the most common ways that a charge nurse helps out their staff is by giving pain medicine to patients on the floor. Too often, charge nurses will offer to medicate someone's patient for them and fail to accurately document the administration of narcotics by skipping a step or two. They either rely on the system to alert other nurses of previous withdrawals, or they forget to document the given dose on the MAR. There are several steps necessary when it comes to giving narcotics and charge nurses, not having the same routine, tend to forget or get used to skipping certain steps.

Until one day when the pharmacy performs an audit and finds that for months, narcotics have been removed without proper documentation. Now, this nurse will be suspected and accused of drug diversion. Drug tests may be ordered, and the nurse will likely be terminated for failing to accurately document narcotics and/or for diversion, both of which are justifiable reasons for termination. Termination, however, is just the beginning.

When a nurse is terminated for suspicion of diversion, there will most certainly be a complaint filed with the State Board of Nursing. Remember, nurses.... If it's not documented, it's not done! Trying to prove a negative after the fact is very difficult, if not impossible. When there is a suspicion of drug diversion, the Board's staff will likely obtain the nurse's pharmaceutical history, order the nurse to undergo a chemical dependency evaluation, and request a meeting with the Disability Advisory Committee (DAC) who will make recommendations to the Board.

After all of that, even if a nurse is innocent of diversion, if the Board is not convinced, he or she may be placed on probation for up to five years or more in order to "document" that the nurse does not have a chemical dependency and to ensure that he or she is safe to practice nursing. Keep in mind, however, that even if the Board finds that there is absolutely no evidence of drug abuse, the nurse will still be subject to disciplinary action for unprofessional conduct and for failing to meet established nursing standards.

No matter what format is used in a facility, accurate and complete documentation is an absolute must in order to avoid losing your job, disciplinary action by the Board, and malpractice suits. The question is not will you suffer the consequences of failing to thoroughly document but, when. If you or someone you know is struggling with the current system at your facility, first, ask yourself, why? It is quite possible that limiting beliefs and fears are interfering with the ability to successfully adapt to the new way of charting. To ensure success, one first has to believe that success is possible. Have the courage to speak up and ask questions. Team up with someone who is already successful and fluent with the current system as a mentor and be sure that you understand each and every step necessary to be in compliance. Your license depends on it!

Supervisors need to be consciously aware of which nurses are struggling with documentation. Oftentimes, it is easy to see what is not being done. I am frequently asked, "How can I get my staff to document more." Recognizing that there is a problem is the first step. However, it is important to remember that each person is different and firing nurses for failing to document may not be the best answer. There are great nurses who just can't seem to get the new system. Work with them. Get to the bottom of why they are struggling and find out what their beliefs are about their own limitations and assure them that they can be successful. Find them a mentor, and remind them of why documentation is so important.

My passion is helping nurses and other healthcare providers learn how to avoid malpractice and improve the quality of care for our patients. We offer in-house lectures for all healthcare providers and we will be conducting our own seminars in our classroom on a variety of subjects throughout the next year. If you are interested in scheduling an event or attending one or more of our classes, just give us a call.

If you have any questions or comments about this article, feel free to contact Tracy L. Singh, Esq. by calling (702) 444-5520 or send us an email at tsingh@tlsinghlaw. com. Visit our website at and look for our upcoming events and seminars on how to avoid malpractice and protect your license.

Tracy L. Singh, RN, JD
COPYRIGHT 2007 Nevada Nurses Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007 Gale, Cengage Learning. All rights reserved.

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Author:Singh, Tracy L.
Publication:Nevada RNformation
Geographic Code:1U8NV
Date:Aug 1, 2007
Previous Article:Nevada Nurses Association 2006 treasurer's report.
Next Article:Certified medication assistants.

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