And now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as a Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultations to physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We thank you so much for being here with us today, Laura, and invite you to go ahead and kick us off this morning. Great. Thank you very much, Lindsay, and welcome, everyone. We're talking about a topic today that it has to live in our environment, and that's documentation. And it can be challenging at times because we're getting so much information, and we're very busy, and it's hard to keep it straight at times. And so that's why I did want to kind of compare documentation to something like this, while I go through all of my videos here, and try and get this to work here. Wix, one platform. And I apologize for that. I was hoping that video would work, but in the interest of time... Okay, Laura, I think it was... Look, there was maybe just an ad or something there that was coming up first. Yeah. Okay. Let me come over here and see if I can do it. Okay. One more time. Shop the best deals of the year. If you don't mind, and bear with me, there's about 30 seconds here. But yeah, let's skip. There we go. This man right here is my great-grandfather. He's the first cat herder in our family. Herding cats. Don't let anybody tell you it's easy. Anybody can herd cattle. Holding together 10,000 half-wild short hares, well, that's another thing altogether. Being a cat herder is probably about the toughest thing I think I've ever done. I got this one this morning, right here. And if you look at his face... He's a good cat. It's just ripped to shreds, you know. You see the movies, you hear the stories, it's, I'm living a dream. Not everyone can do what we do. I wouldn't do nothing else. It ain't an easy job, but when you bring a herd into town and you ain't lost a one of them, ain't a feeling like in the world. So as far as what I wanted to show from that video, it's that herding cats, doing the documentation and collecting all that information, it's very similar to herding cats because there's so much involved and it's coming at us constantly and sometimes you don't know where it is. So let's go ahead and get started on why we are here. As your staff is really, they're there on the front lines and they do see, they hear so much, so much information is coming at them and they interact with many other departments. Also people, patients, families, they're having to interact with and sometimes even CMS surveyors that happen to be on site. And eventually, and hopefully, everything that comes into you regarding your patients does end up in the medical record. Now, the one thing we have to also keep in mind is the record is used for many, many purposes and it's not just communication of the patient care. It also can be used by plaintiff's counsel in a liability case, but also your defense counsel in showing what you did. They've noted that documentation deficiencies, it's a big contributing factor in our nursing professional liability claims, not just physicians, but nursing also. And they found that not documenting or heaven forbid, falsifying that information, that increased in the frequency and severity compared to just a couple of years ago. I've got the, where that came from, the nurse service organization did some research on that and put out that article. American Nurses Association, that's our professional organization. That's the one who CMS might go to to get some information. Well, they note that documentation is so critical for effective communication as that really is the basis for demonstrating and understanding what we did for that patient. It also helps provide and support the quality of the care that we gave. It's tough, I recognize that. I remember when I was doing bedside nursing, go into your initial assessments, come out and they're like, oh, I stopped to document. And sometimes it ended up being very long and laborious. And yeah, at times it was a burden. And at times it really took me away from what I was thinking on needing for care and actually taking care of my patient. So Lindsay mentioned we have a few questions. If you wouldn't mind, go ahead and put this up for me, Lindsay, and let me see what we have. Perfect. So you all should see this question on your screen that says, our staff received education on the importance of documentation before working at our facility. Yes, no, or possibly not sure here. Those of you who just joined us in the last couple of moments and missed our introduction, there will be a few of these following questions that will be on the screen throughout the webinar today and that you'll have the opportunity to answer. We'll also pause to address any questions that you have for Laura. Up to that point in the presentation. So at the bottom of your Zoom window, you should see that Q&A option where you can type in your questions. Or if you don't see that as an option, you can, of course, utilize the chat as well. And really, this is somewhat, it's beneficial for both you and for me because it helps me get a good feel for where everyone is, but it also might help you gain some insight. Do my staff really know what to document, how to document when they come in? If you have a lot of new graduates, yeah, they usually are pretty fresh and have a really good basis understanding. Sometimes it's those more experienced nurses that we sometimes want to revisit with as far as the importance of documentation. And I have a case in here that talks about not only documentation and communication through that, but then are you communicating with the physician or the provider also? Okay, there are those results. All right, good. And it's good that a majority of them are getting that education because it's crucial because we do this to support the entire healthcare team. It's not just doctors and nurses, it's everybody, it could be consultants, radiology, pharmacy. They would need to know what's in there. And it also helps with informed decisions. Now you think, okay, how does that happen? Because we can help document what is the patient's level of competency at that time? Because if they can't understand or they don't have the ability to understand, how can they make that informed decision? And of course it does help with continuity of care, that we are continuing to communicate how are we progressing. So documentation overall, we know it reflects what is going on with that person. The care that we provided, the flow of those needs, how did we need them? In other words, were they so critical ill when they came in and now we've given this care and they're starting to improve and those needs change. Maybe they improve. Also, have we had any significant developments, good or bad? Did we have a patient who was in ICU for so long, very critically ill, get them out of there and sure enough, they come out with C. diff. How did they respond to our interventions? Did they get nauseated with that medication? Did they have an allergic reaction? Interactions with others. Did we communicate with PT, OT, maybe discharge planning? How did that happen? And then of course we wanna make it contemporaneous as possible, at the time or soon after when that care was provided. So there are essential elements that go into this. And again, this is from American Nurses Association, those principles on nursing documentation. We of course have our assessment, what were the problems the patient communicated with us? Did we communicate with other providers? Also, what were the patient clinical parameters? What were the vital signs? What was their ability to walk, sit, stand? Did they respond in any outcomes? What were the plan of care? Now here you have to include social cultural information about that patient. Do you have a patient who might have a religious deterrent to receiving blood or blood products, but yet they need something. So that's what we have to take into consideration. Of course, our ever lovely medication record, that's so crucial. But it's not only about the patient, those are things, documentation overall. And that's not just nursing documentation. It has to do with everybody because they use it credentialing. They use that, the documentation by your providers when they're looking at credentialing because they need that to monitor them if there's an issue that comes up. It's also how do you as a facility comply with the standards that do govern, not only the profession, but your hospital operations in general. How are you providing those cares? Now we know it's very important in regulatory actions. When they come around CMS, the accrediting organizations, they're looking at our medical records. They're looking at the documentation. They wanna make sure we're taking those standards of care. And also is there evidence when maybe we do need to modify the care that is provided to that patient. All these accrediting organizations, again, they look at our documentation and they have requirements for it. Whether it's CMS, DNV, AAAHC, doesn't matter who it is. They have certain standards they expect us as providers to meet with documentation. So just briefly on CMS, I know some of you may have had an opportunity when Georgia Hospital Association puts on their programs and we've done medical records and some of the other conditions of participation. So here's just kind of a brief recap. And this is in the medical records section, appendix A. Records have to be accurately written, promptly completed, properly filed and retained and accessible. Because if we can't get that information, we can't take care of our patient to the full ability we could. The record has to have enough information to justify why that patient's there. Why did we do the treatment? What was the basis of that documentation? How did the patient respond to that care? 450, this is what the record has to include. That's a must. It must be legible, complete, dated and timed and authenticated. That means who made that entry has to put their documentation, their signature in there. But CMS also makes multiple references in the entire appendix A manual and really appendix W also for critical access on where documentation pops up. Restraint and seclusion is big on documentation because they want us to go in and evaluate the patient. Are they still okay in restraints? Do we need to continue restraints or is it time to remove them? Pre and post anesthesia evaluations. What do we have beforehand? What's their status afterwards? If the patient files a grievance, they really look at that because they wanna compare what was the basis of that grievance to the care that's documented. Plan of care, advanced directives. Can we have to document? Does a patient have one? Yes or no. Do they want information on one? Yes or no. And then abuse and neglect assessment. And those can be challenging. It's always hard when you have a patient who you believe may have been treated not nicely either by a family member or even by the staff. We have to document that. And what did we do and respond to that? Joint commission, it's in their record of care. Of course, just similar to CMS, our entries are authenticated and it's entered timely. The record has, again, why is the patient there? What did we do for them? What was their diagnosis and assessments? Conclusions from our medical history and physical. So many more, again, very similar to what CMS says. Well, then there's the other arm of it, the legal component. Our documentation is evidence. When it's incomplete, it's false, untimely, illegible, inaccessible. In other words, we can't get access to it because it's a case, misleading. Where there's lapses in care or inappropriate care. Maybe there's inconsistencies or discrepancies. All of those can really jeopardize the defense of really a defensible case. And it exposes us to more liability that's not necessary. Now, some publications, believe it or not, some publications actually will direct plaintiff's attorneys to look at the nurse's notes. Because a lot of times there's much more consistent information on that patient from 7 a.m. until 7 p.m. than what the physician's documentation can show. And that's why those agencies, those publications say, go look at the nurse's notes, see what's in there. We're familiar with our expanded discovery now, looking at that metadata behind the screen, so to speak. But that's not all of it. It's now text and emails going back and forth. There is a new rule out by CMS. Yes, you can text patient information, that's okay. You just have to use that platform, that very private platform, in order to make sure not only it's secured, but it gets into the record. Sometimes that doesn't happen. And that's why when those issues come up, when, say, physician texted or physician reached out and the physician said, I texted him back, he's like, great, give me your phone. That could be their personal phone and they have to turn it over. Again, they're looking for those inconsistencies. What is the electronic record and what did they say in a deposition? There is a resource out there and it talks about avoiding the courtroom. I don't know if the CEs are still available. This is through nursing from 2011, but it talks about how to stay out of the court, or out of court with proper documentation. In fact, they even list some red flags, that notes are sloppy, they're incomplete, they're not timed or dated, or they're out of sequence. Now, sometimes that happens. We know that happens. And that's where you are just so tied up and busy that by the time you get around to documentation, someone has entered after what you would have entered. Late entries are okay, just make sure you are working or have that education from either your charge nurse or your legal counsel, or even your risk manager. What's the best way to do this? Erased or obliterated entries. Yes, you can do the cross through and your counsel said it's okay or risk manager, but be very careful how much you're obliterating it. Statement completed an event report, right there. That's a red flag that something happened during the patient care. We know what it is, it's our incident report. You don't have to include that factor of counsel, your risk manager will probably say, please do not enter that statement in the record. Just say what you found and what you did. The rest can go in the incident report. And then finally payment. We use that for reimbursement. Was that patient really that sick? And did they need that care? Did they need that intensity of services? CMS will use it crediting organizations. Now, granted they're not for payment, but if they have deemed status, yes, then you can have their survey and their review without having to go through CMS and still get paid. And then private payers, your blues, your sickness, they also use it. There's also others who use it. And this is research. How did that patient respond? The analysis of the data, that's so essential from our evaluations. Quality process and for improvement. This is really where we get most of our evidence to continually work on our performance outcomes, our metrics that we're working on. Did we vary from the established guidelines? Why did we vary? Is there a better way to do it? And then licensure investigations, medical board, nursing board, and defending nurses before the board. That's what they relied on. Well, and then they would go talk to people, but they really looked at that record to establish, did that nurse meet the standard to which they expect? Finally, disability determinations, custody determinations, what they're looking for is, how is this person taking care of that child? Competency determinations. So those are just the multitude of how much our record, our documentation, whether it's physician, nursing, doesn't matter how crucial that is in all of those components. ANA has six principles of documentation. Yes, again, the asterisk means I have the resource in the appendix. We're gonna look at the characteristics, education and training, policy and procedures, our protection systems, our entries, and then standardized terminology. And Lindsey, I think this is our second question already. It is. Let's go ahead and get that one up here on the screen for everybody. So this one, you should now see that says, our EMR preloads patient information and is at times repetitive to where I'm concerned as to its accuracy. Yes, no, I prefer not to answer. We'll give you just a couple of seconds here. Now this isn't saying there's anything wrong with carry forward or preloads. There's nothing wrong with that because it can't be a very big time saver. We just have to make sure it's accurate. That's what we have to do. Okay, I see a couple of responses still coming in here. Great, okay. All right, there are those results. All right, so yes and all right, we're about to split. Okay. So here's, and I'm gonna go through these six principles. Number one, the characteristics of documentation. I just like going to that one on the right-hand side that says legible, readable. In other words, does it make sense when you read it? Of course, accessible, accurate and relevant, auditable. Can I look at that record in an audit and understand, yep, that's what they did and it flows with what's expected? Yep, that's what they did and it flows with what's expected. Is it thoughtful? Do we put consideration, our critical thinking skills when we're doing that documentation? Does it show our process, nursing process in particular? And can we get it back on a permanent basis if we need to? In other words, you go back, you'll look at it and say, yep, okay, I know what happened at that point in time. On education and training, this is referencing to that individual who's making that entry. That education and training and the elements, the technical elements. So that's where your organization has to have those policy and procedures and addressing any staff issues. Does that particular computer system, how it works, is it workable? Is it functioning for me and efficient? Because nurses have to understand how to use that computer system and be proficient in it. It doesn't help and it's not, again, it's not efficient if they're fumbling around and trying to figure out where do I put this? Where was that information? What am I supposed to be looking at? Of course, nurses and everyone has to be familiar with your organizational policy and procedures and especially, right, what happens if the computer crashes? It's down, it's locked out for whatever reason that that EHR is not available. What do they do if there was an issue of an unlawful hacking within your computer? What do you do? How do they document? Do they go back to old school paper or is there another system that they can use? Again, nurses and physicians, everyone needs to know what that is and the protection of our information. Of course, we use our industry standards. What does CMS and the government say we have to do or your organizational policy and procedures? How soon does your organization allow that computer to stay up when nobody's looking at it? In other words, when is this blackout time? Is it 30 seconds and nothing done on it or is it 10 seconds? That's up to your organization. Of course, we're protecting our patient information, our identification, but don't forget about you guys, your professional information, your nursing license, your nursing name, your physician's name, organizational information. That's all part of this where we have to keep our documentation. Of course, unauthorized access. We know there's been an increase in hacking information being illegally accessed and now OCR is fining us and other facilities if there aren't inadequate measures. That's why tag 438 says you must protect security of records. We are now required to do a security risk assessment and there is one out that is available. It's free to you. I believe I have it in the appendix. If not, I'll get the link over to Lindsay to share with you. It's a nice link. It has one that you can do your assessment by Excel format. There's one for Word. However it works for you. But it's so crucial now because they are fining us. And this was 5.5. That was 5.1. That was way back in 2021. Now the largest settlement just happened recently. This was Anthem. 16 million because of a data breach. So again, OCR, they're getting serious on these fines. They really want to try to lock them down because they weren't taking action in doing and protecting what they're supposed to do. Then there's five principles of entries. This is number five. We're almost to number six. Accurate, valid, and complete. Authenticated. I know who made that entry. Date and time stamped by the author so we know when it happened. Readable and using that standardized terminology, those acronyms, those symbols that there's not anything, it could be misconstrued. If I use the acronym SOC or SOP, let's do SOP. That could be standard operating practices. But it's also could stand for standards of practice. Which one is it? That's why they want them standardized. Which brings me to my next question. I know we're getting these pretty quickly and we will get to the cases here. So Lindsay, would you put that one up? Absolutely. I'll get this one on your screen now. Okay. And this says our electronic record system does not permit unauthorized abbreviations. Yes, no, or do not know. I'll give you just a couple of seconds here. And this is our last polling question, I believe, Laura. So if you have any questions so far, of course, you can go ahead and type those in. But we'll also have time reserved at the end of the webinar to address any questions that you have for Laura as well. As we go through the cases, I've got questions for you to think about and perhaps respond to as we're looking at the cases and the documentation that was entered. Okay. We've got good responses here. All right. Oh, does not. Okay. Doesn't permit that. Does not permit. Okay. So what is our sixth principle? Standardized terminology. How many of you remember a couple of years on, I guess, not a couple, several years ago when we had that do not lose list? That's still out there. These terms, we have to use certain terms of the planning, delivery, and evaluation of care. Now, this does say nursing care only because it was through the ANA. But I argue that it should be for any care that's provided, whether it's through physicians, physical therapy, occupational nurses, I don't care. So some of those charting abbreviations, make sure you have them. They're approved usually by nursing and your medical board or medical staff. So you know, yeah, we're all going to agree to these terms. And if anything's outside of it, then what are we going to do? What other options? They do talk about that, the ANA, clear accessible. And they identify, oh, I already mentioned that. Excuse me. So as far as burden reductions, again, the six domains of burdens, this is the burdens of documentation. We have regulatory, we mentioned. Reimbursement, our payers. Usability, following evidence-based or human factors. Interoperability, duplication of data. Self-imposed on the culture of what should be documented. That adage of not documented, not done, a lot of your defense counsel will say, no, that's not true. Because we do so much every single day with our patients to put every single thing into the record that we did do, we would have voluminous charts that would probably blow up the ER system because there's so much information. So let's go ahead and start with our case. First off, the basics. This is a story about the patient, what they did. What were they when they first saw them? What did you do for them? How did they respond? Did you do any education? Which, yes, you're probably doing more than you realize. And then how are you going to tell them to take care of themselves once they leave there? The discharge instructions. It has to be factual, complete, objective, readable, and timely. Timely means contemporaneous to the care that you did provide. Factual is what happened. It's not the interpretations or how you reacted, but what did you see? So here's an example of objective. This is the definition. It's actually from a communications case. Objective medical documentation. That's written documentation of what you saw, observable, measurable, reproduced findings from an examination, supporting lab or diagnostic test, assessments, diagnostic formulation, including x-rays, blood pressure or vital signs, lab, functionality assessments. In other words, can they get up and move around? Psychological testing, et cetera. That's objective. Complete means there's enough information that supports what you did. And it identifies with enough specificity to convey what you're trying to convey. So here's some examples of complete. We have a 48-year-old presented. Complained onset of mid-sternal chest pain rating to left arm and back. Alert and oriented times four. Paled, diaphoretic, nausea and vomiting times one. Pain began while shoveling snow. Lungs are clear. No rubs, murmurs or clicks. IV right forearm, blood pressure. You've got those listed here. EKG elevated ST with occasional PBC. STEMI protocol started. That pretty much tells you what happened from the minute they hit the door. What did you see? What were your observed diagnostic readings or findings? And what was your plan? Next one. 16-year-old male. Came in via EMS with a gunshot wound right upper quadrant. Paled, diaphoretic, grunting respirations. Responsive to name. Vitals 96, 40, 162, 45. IV both arms. Wound right upper quadrant with bleeding. No exit wound noted. Condition deteriorating. Intubated number eight with ease and two OR. So this is a very, again, these are both really complete. Tells you what did you see? What did you observe? What was your assessment findings? And that's what you had to do. So the question, are these complete? Here for the third time in two days. Complaint of a back pain between the shoulder blades radiating to the chest. Vital signs stable. Asking for something for pain. Maybe demerol. We'll give Toradol and DC. I don't know. It's not very complete because I don't know what the vitals were. I don't know what was their assessment. Anything else they did for this patient besides, we'll give him Toradol. Is there enough that you can assume care of this patient? I don't know. I wouldn't take that. This patient did come back. He had a dissecting aortic aneurysm and died in the ER. Is it readable? Can the person follow essentially the conversation? And does it make sense? Those of you who have worked in nursing, you've probably seen some of these documentation. Now, the good news is this is back from 93. So yes, it's an old entry. But that's a tough one to try and decipher. Now, this one is actually from nursing notes. So it's not just physician. This is a nurse that made these entries where it's a little bit hard to follow it. We do see something in here about Dr. Kim answered. That's fine. Nothing ordered. So that's a little bit questionable on that documentation. What don't you want to document? And that's just what I showed you one of them. Subjective comments, incident report we talked about, and jousting. Now, getting what that nurse documented, that was kind of close to what was said. And so this is the acceptable. Would you agree with this? Patient here for dressing change, final analysis. Dr. W, wound pink, edges well approximated, no bloody drainage. Patient reports much drainage at home. Dressing change four to five, dry now. This is where I think we kind of get off the rails. Patient unhappy with the doctor. He only talked to her one time. Not since. Many questions. This is not acceptable. Told her I would communicate with my manager. Many patients have reported Dr. W is nonresponsive. So if you had seen that in your documentation with your staff, what would you have done? Would you have gone to that person and say, we need to talk about how this isn't going to happen? Or would you let it go? Because it's true. Why not? This is a good example of jousting. And it can't be in the record. It doesn't belong there. Most cases involving documentation show that they usually resolve around one of these top three. It's not there. The documentation is missing. Inaccurate content. And then it's what they call mechanics. They put it under that overall heading. Whether there's errors in transcribing. There was a delay in communication that came in late. Or it simply couldn't read it. Because, again, it was handwritten. So these are some of the top issues that most malpractice claims really end up determining whether it's for the defense or for the plaintiff. And these are things we can fix. That we really, really can. So now I'm going to move on to the cases. Before I do that, are there any questions right now, Lindsay? I don't see any at this time. Oh, good. Now we've got time for these. All right. So let's talk about patient care. Patient comes in long history of IV substance use disorder and alcohol use. He came into the ER. He was involved in a fight. He had severe back pain. He was hit over the back with a chair. Tox screen was positive for heroin and alcohol. But he denied heroin for 24 hours prior to coming in. That's not okay. So he's still positive. UA shows some bacteria and blood in his urine. So here was the assessment and the initial care that was given in the emergency department. Patient yelling in ER demanding something for pain. His assessment, some weakness to both legs. Those are his vital signs. He's a little hypertensive. Pulse is up. Temp isn't bad. It's up there, but it's not bad. So they ordered Tordal, not much relief, Demerol and Visceral and antibiotics. 20 minutes after the Demerol, he was a little quieter, but his exam had not changed. They were keeping an eye on him. They sent him down for plain films. There was a little cloudiness over the thoracic area. They believe that was simply due to the swelling from the fight and maybe some soft tissue swelling. So they ended up sending him home. Instructions follow up with your PCP in two days. He comes back three hours later. Now his friends are actually having to carry him because he can't bear weight. He can't use his legs. He's in severe pain. And now those vitals are up. His pressure's up. His pulse is up. Now his temp is also up. Neuro exam unchanged with the exception of documentation of leg weakness. That didn't change. Now there's very little documentation to show anything else of a neurological exam had been completed. In deference to the providers, he was not a very pleasant person. He was in extreme pain and he was hurting and he needed some help. So he was a little challenging in taking care of. He was admitted for further evaluation for care. Over the next two days, this pain does not get any better. Vitals are unchanged since that second ER visit. So his pressure's up. His pulse is up. His temp is elevated. Needless to say, he was a little irritable and not cooperative. The nursing documented he refused any care, refused to get out of bed, and there were no changes to the orders or any additional diagnostic testing. Both nursing and medicine, though, documented. Unable to use lower extremities or stand and continues to report severe back pain. So the one physician goes off call and the next one comes on. It's on the weekend. And he said, oh boy, we need to check this out. This doctor comes in with a clean eye and takes a look at the guy and goes, let's get an MRI of the entire spine, given his presentation and his past medical history. We got a mass from T6 to L3. They do surgery, take out the huge abscess and his gram negative staph. After three months, he is now still a permanent paraplegic. This one did settle out of court for a very high range. And part of it was we had the physicians involved and we had the hospital involved. So they do the RCA and they involve pretty much everyone who saw, touched, or spoke with this individual. From the department, inadequate assessment by everybody, nursing and medicine. Yes, the patient was challenging. Yes, it was a busy shift. But unfortunately, the physician had anchored on the diagnosis. This was due to his fight and a substance use disorder, why his pain level was so high, because he was tolerant of the medication. They didn't do anything else on that respect. On the unit, minimal communication with the physician. They go back and they look at the charting. Very little was documented. Patient still complete pain, intense pain, can't use legs. There was no documentation that that was communicated to the physician. And also between the providers. And this was the ER provider and the floor provider. How much were they communicating, if anything, what was in there. Sometimes that doesn't occur. But again, they felt it really should have, when we have a patient with such a dramatic change in his physical ability. They said the experts that reviewed the case, they were very concerned with that limited assessment in the ER. And that was the first ER visit that should have been cleared up. What do you mean cloudiness on the spine film? Would that have shown up to that degree if it were simply muscle or soft tissue? Was there further investigation? Was there an overread? Because our physician read that one, not the radiologist. And then finally, they didn't even think about the UA. Why is there blood and bacteria in the UA? And especially since this person continued to report pain and leg weakness, that wasn't further delved into. If they were thinking UTI, okay, he got one done, but that doesn't explain the leg weakness, what's going on with there. Here's what the nursing expert happened to say. They were very concerned with the lack of assessment of the leg weakness. They could understand why you don't want to go talk to this person or try to work with them, but maybe you could have done more to assess. Now, if he's having that much pain, he's probably moving around and trying to get comfortable, but his legs aren't moving. Why is that? His temperature was rising. And then finally, that weakness was a new sign. And really, we should have communicated, he can't stand now again. There's something going on with his legs. So again, this case did settle in the high range because the documentation didn't support what could or should have occurred with that patient. And if it's okay with you, Lindsay, I'm happy stopping for any questions on this particular case before I move on to the next one. Yep, absolutely. I don't see any questions at this time. I did just see a comment asking if the presentation and recording could be sent out to everyone afterwards and saying that it's wonderful info. So thank you so much, Laura. And I was actually typing my response, but just for everyone's knowledge, yes, you will all have access to the recording. So you can go back and review these cases and Laura's notes here so you have access to the recording of today's session and the presentation itself. And I'll link the slides there again for you all in the chat here in just a moment. But if you do have any questions for Laura or comments regarding these cases, please type those into the chat or just Q&A for Laura in that Q&A option as well. Great. Okay. Now we're going to talk contemporaneous documentation. We have an 80-year-old admitted for multilevel spinal fusion. Lives alone in a rural area. Closest family member is 90 minutes away. Both the patient and son went to discharge plan evaluation. And they asked for a discharge plan to be done. Surgery goes along great, no problems. Patient gets about two sessions of PT. And the day after surgery, she said, okay, you're ready for discharge. So the patient calls the son and said, you need to get in here. They said they're sending me home. Son calls the physician and said, hey, what's going on here? But the physician never called back. He was only able to leave a message. Well, the son also talked with the charge nurse who came out and said, well, we're not going to be doing one. That one's not going to be done. But no explanation as to why. Patient goes home that next day with the son. He was able to stay for about another two or three days. This patient had a lot of difficulty getting around. There were stairs, there were rugs, there was a lot of pain involved with this surgery. On the fourth post-op day, she falls at home, having to go to another hospital that's a lot closer. The family patient filed a complaint with the hospital and the state for failure to provide any discharge evaluation, planning, coordination, nothing. They just sent her home. So what they found out in the investigation here, this was a very high census time. Yes, it was the flu season. And they were short-staffed. And so what they needed to do was close one of the floors and transfer patients. During the investigation by the state, again, the state came in, they found that the staff talked about a memo that came out saying we need to discharge as many patients as possible because we're short-staffed and we need to close one of our floors. The staff reported they didn't find the memo, by the way. During the meeting with the family, it was reported that evaluation was done. And the family said, no, that's wrong. One was never done. They never talked to us, nothing. So they asked for a copy of the medical record. When they did that, the documentation noted a evaluation had been entered and it was dated the day after the family and patient filed a complaint with the state. Now, if that's not a red flag, I don't know what would be. The outcome, short and sweet, was that the hospital wasn't reimbursed for the entire stay. The surgeon was reimbursed. But the hospital was not. They did a full complaint survey. They were placed on immediate jeopardy. And further documentation of similar cases also showed a pattern of early discharge and no discharge planning had been done. The physician was reviewed by peer review. That was a little unpleasant. But again, they did kind of say, hey, if the family asked for it, you're required to do one. And they didn't do it. And nursing, that one who entered late documentation, actually was referred to the Board of Nursing and ended up with a written admonition because of that contact, conduct. You don't do it after the fact. Leave it alone. In fact, probably your risk manager in-house counsel will say the same thing. If something's happened and there's a certain amount of time that goes past and you remember, oh, that should have been documented, you don't touch the record. Talk to them first. Because they will advise you on what to do and not to do. Because it looks like you're trying to enter that CYA entry. And that will look bad if it ever goes to court. What are you trying to justify or hide? Alterations, they're now relatively easy to identify. We have that metadata. We have the time stamps. And it just looks bad and can jeopardize your license, too. Providers, they can be vined by the Office of Inspector General if they believe it amounts to the level of fraud. And it can result in the reversal of evidentiary burden. What does that mean? Normally, in any professional liability, and for those of you who know this, kind of bear with me here, in normal cases, it is the plaintiff who has the burden to show this is what they did wrong and how it harmed me. In this case, that switches. You have to show, you as a defendant have to show that, hey, nothing we did harmed the patient. In fact, we did just fine. What we did was okay. we did nothing to have harm. The patient doesn't have to prove it. You have to prove it. So that's where it shifts it. Jousting, this talks about a patient's position in bed. We had a left craniotomy. I'm sorry, that's a different one. This is the left craniotomy I'm positioning during surgery. Into evacuated hematoma. He was out hiking, climbing. He was here in Colorado and it's climbing and he fell. And we had a great neurosurgeon. He had a good PA. He'd worked with this PA for some time to do the assist. And there were no problems working with the PA. The patient was positioned on the right side and prepped and draped by the PA. He was in prone position for the prep and the marking. That's normal, that's where he would have been. Neurosurgeon was not in the suite at the time that did occur to confirm and verify everything. Upon entering the room, the radiologist, the surgeon looked at the film, confirm what site and site of the location for the surgery. Well, it was a very short and limited timeout that did occur because this surgeon seemed to be quite rushed and frankly, he didn't confirm the timeout. The incision was made, cranial window obtained. Once he opens up the cranium, he starts looking for the hematoma and can't find anything. It's like, where in the world is this thing? It's right there on the film, why can't I see it? That's when the scrub nurse speaks up and says, why is the PA on the wrong side? So calls for a hard stop, but unfortunately, the surgeon continues to work. He's looking for that bleed. Now the scrub nurse, she calls for the circulator to get in there. Anesthesia even comments, hey, the patient's in a prone position. She glanced at the films, notes the site indicator has left on it. So again, we've got two people saying, you need to stop what you're doing. It was again, only after anesthesia mentioned, that the surgeon decides to stop. Now we see we have the wrong side. They take out the cranial bone, the sutures, the incisions. They put in the bone and do the sutures and they go to the right side. Now the surgery commences, everything's fine without competition. They get the hematoma out and there really is no patient sequelae as a result of what happened. So here's the documentation. I did modify this and just kind of shortened it given how much information goes into some of these. Pre-op left subdural hematoma, left craniotomy with evacuation. Operative report, 27-year-old, rock climbing, landed on his left side and et cetera, et cetera. He was prep positioned by my PA whom I've worked with for three years. This is the first time he's made a mistake with positioning. He must've gotten confused, placed the patient. Before confirming the site, I don't know why he made such a mistake. I don't think they worked together much longer after that documentation happened to be made. RCA, patient was positioned by the PA. No, that's fine. His state scope of practice allowed that to happen. He could do that. And it was done to really expedite the surgical process. What wasn't done, the position was not confirmed with the surgeon. Again, he had worked with this surgeon, he knew what to do, but that was outside the hospital's policy. The position wasn't confirmed with the radiology film. Again, outside the hospital policy. He glanced at it, not realizing he was looking at the wrong side of the patient as opposed to what the film was up there. Patient was prepped and draped without a timeout confirmation because of course that's what the surgeon wanted, outside policy and procedure. So when I got three strikes so far on outside policies, timeout, not done. Surgeon usually in a hurry and he simply didn't wanna wait. Nurse anesthesia didn't speak up because that was the culture. This surgeon did have some interpersonal relationship issues with the other staff, was known to be terse and somewhat impatient with them. And so that's why there was no communication. They just, they didn't wanna get in the line of fire essentially. RCA continued here. Surgeon, he was aware his entry referenced the error by the PA, but he did it to make a quote, accurate record. End quote, those were his phrases during his deposition. He's not sure why the patient was put in prone or why the PA put him in prone, completed the prep without confirming with the radiology film. As for the timeout, he trusted the PA and the team because he had worked with them before. The PA, he had no idea about the reference in the record until he was at his deposition. He was told by the surgeon to complete those steps. He knew what the policy said, but he didn't wanna rock the boat with his employer. Now you look at these and you think, those are not good reasons. And you're absolutely right. They're absolutely right. So what are the concerns here? Well, first off, who is responsible for positioning in your hospital? Who has that ultimate responsibility? Because I can tell you right now, it's the physician. The person doing that surgery has to confirm that. And that's with everybody on the team. What about the documentation? Is it accurate? Probably. Is it complete? Yes, maybe too complete, but jousting's in there. And jousting comes back to finger pointing. And that is just, it's not helpful because really then everybody just kind of sits back and said, who's writing out the check? That's pretty much where it gets to. I've seen it before. I've had to work with physicians and others to say, please don't put that in the record because we can't take it out now and it's there forever. And now we have to explain it. And what should be documented? What about the culture within that hospital and the surgical suite? Culture is not an easy fix. I understand that. And sometimes you can pick that up in the documentation where you know things have happened and you said, I called the doctor and he didn't do anything or I told the nurses to do that and they didn't do it. That's your culture. That's what we have to try to work on. We're here for the patient, not for, you know, make sure that everybody is very happy, but we need to make sure it's respectful. Here are the expert comments. Nursing, didn't speak up before the incision. Waited too long to do the hard stop. Really, it should have been done before the incision. They didn't even prevent the start when timeout was not completed. Physician didn't do the timeout, didn't confirm position site side and the PA stepped outside the scope for the practice. In other words, not confirming what was done and not making sure it was done with the physician and didn't simply follow policies. What happened here? This is an interesting case, because again, there was like really no harm to the patient from the surgery, okay? He was informed of the incorrect site, but unfortunately he got ARDS, but it was not related to the craniotomy. It was actually related to the other issues from the fall where he ended up having some lung issues and not moving and just having some sepsis associated with it. There was some cranial swelling that led to impairment, but again, that was from the ARDS, not the actual surgery. It was not related to that initial fall. Now, the parents here were the ones who filed a professional action, naming the entire surgical team in the hospital with lack of informed consent. Because what happened here is that had this patient known that this physician had some issues with interpersonal relationships, or perhaps he had issues in the past with his surgical proficiency, in other words, other complaints, they never would have used him. Now, this surgery was somewhat of an urgent need because he fell and he had this swelling going on. They knew the hematoma was there and they had to get it out. And so the question was really, are you gonna wait around to go search out his past board of medicine issues before you decide, hey, I'm gonna have you? Or do you really go with what's there and know, yeah, you could have a good outcome? He did. From the actual surgery that was performed, it was good. He had no problems. It was the after effects from other issues that caused his injuries. Surprisingly, it settled in the high range. Anything else you would offer for this hospital? I'm gonna take a breather here and just see if there's any comments on any of the three cases we've gone through. Absolutely. Have any comments here related to this one? Anything else you may offer for this outcome? Go ahead and type that into the chat. We're happy to address those. And if you have any questions for Laura related to this or any of her previous cases that she's discussed, please feel free to type your questions into that Q&A option. Susan, I see that your hand is raised. If you'd like to type a comment in the chat, you're more than welcome to do so. And I can reach out to you and see if you have any questions as well. Now, as far as getting any additional information on these cases, I probably can't get to the case because these were mainly non-litigated or they weren't published. So I cannot go get those cases, unfortunately. Okay, I don't see any comments at this time, but I will let you know if I didn't see any, Laura. Great. Just kidding. As soon as I say that. Yes. There's one that says for the last case, an emergency does not change the fact of the physician. Yeah, right. You're absolutely right. Yes, it's an emergency, but we still have to do care. And again, this physician had an issue of not taking time to follow the policies and do the time out. Now, I'm gonna tell you, this happens more often now than we like to admit. It still is occurring where timeout is not done or an ineffective timeout is not done. It's more of a, yeah, yeah, yeah, yeah, yeah. And everybody moves on. They're not doing the timeout for what it's designed to do. Inadequate monitoring. We have an 85-year-old. You know, unfortunately, some of these are, unfortunately, of our older population, but we have a nursing home resident, history of high blood pressure and TIAs. She's inpatient for dehydration. She is on a lot of medicines, a lot of them. They recently noted while she's in the hospital, and also in the nursing home, she'll wake up at night and kind of walk the hallways with her walker because she's bored. She needs something to do. Nursing home staff allowed that because she wasn't disruptive. They noted that she was stable on her feet and she did fine. There was no issue. And in fact, it did kind of help her stay, get better rest and stay more alert. So once she comes into the hospital, this is the documentation. The first day she's in for dehydration due to the flu. She's alert, oriented, pleasant, still needs help up. And she uses the walker. Seven days later, now they're noting she's a little lethargic. She appears confused. She responds to her name. She knows her family, but she's not sure where she's at, but they can get her reoriented fairly easy. Now this is seven days she's been in for dehydration. So she was getting hydration. Next day, she's up. She's walking the halls at night. Now when they approach her, she seems like, well, who are you? Where am I? They get her redirected back to the room. No problems. Next day. Now this is the physician's notes. These were early in the morning. We believe, because the problem is it wasn't timed. Ready for discharge in the morning where we order all meds. Two hypertensive, antihypertensive, anticoagulant, aspirin 81 mix, Xanax and a sedative. At seven in the morning, they're doing their rounds. They don't find her. They call the family and say, we can't seem to locate her. We don't see her on the floor. Hour later, they finally find her. She's at the bottom of the steps in a fire exit. She's deceased. Family is notified. That was all the documentation that we have. So the legal expert really had a field day with this one. They questioned the documentation of the assessment on that morning before she was supposed to go home. Very limited documentation. Was she alert and oriented? What were her four stages? Place, person, time, date? How about her overall physical abilities? Was she still weak? Remember two days prior to discharge, she was weak and lethargic. Documentation of hourly bed checks. And now they were supposed to be doing this, but they really questioned these because everything sounded identical. Staff, it was also consistently low for how many patients they had. Many medications for the same conditions. They really questioned that. Why is she on Xanax and a sedative? Why is she on those antihypertensives? Is it that bad? Or have we monitored her blood pressure? And really the other thing that they really had a concern with, there were no alarms on the door. So that if you opened that fire escape, was there supposed to be an alarm that went off? At the one she went down, yes, there was supposed to be an alarm. Yeah, you could open it, but an alarm would sound saying somebody's trying to exit when they're not supposed to. The nurse, our expert nurse, really said, I don't know anything about this person to support the care, the rounding and the bed checks. What little was there just simply didn't support it. Again, it was so repetitive, it was almost the same thing. And they were really concerned about the culture on the unit. And they got that just reading the documentation, believe it or not. Why didn't anyone raise a concern about her confusion? Again, seven days after she was in, she was going downhill and no one mentioned it to him. This one unfortunately ended up with a whistleblower. They reported lack of oversight, that patients were often left unattended in not good conditions. Staffing was really insufficient for the care that was required. The state cited them for multiple violations of safety, especially that door alarm. Why was it disabled? Why had it not been investigated? State nursing board investigated the nurse. They actually suspended the license and nursing care simply below the standard of care. And the one nurse was the night nurse before the patient was actually found that they really hadn't been keeping an eye on her. That's what had happened. All right, any recommendations form? What do you want to have accomplished during hourly roundings? What is the purpose behind those? What are you to document with those hourly roundings? And especially with the patient who under your assessment has been known to get up and wander around. You have a patient you know, based upon your assessment has a history or an issue with confusion, with lethargy. What do you expect to do when you can't find a patient no matter what their history is at some other facility? Okay, they get up and wander around, but they're used to that. And they watched the patient, they knew that they could redirect her and they kept an eye on her. Here they didn't do it. Anything else that you would recommend? And I'm just gonna go ahead and have you type it into the chat room. And as I move on with the outcome, Lindsay, I'll pause at the end of the outcome and find out if there's any other recommendations. Perfect. So they did disclose to the family. They agreed to a confidential settlement that included. Now with the hospital, that usually includes the nursing personnel or other employed staff. Board of Nursing reprimanded the nurses required continuing education for two years on it. Hospital granted, they did their extensive RCA. They did put together a good plan of correction. Everybody had to attend that education. And in fact, they did a quiz afterwards. They also revisited compliance, CMS. They did compliance three, six and 12 months after it because that was almost an immediate jeopardy. They were very concerned with this hospital. And any other nurses who refused to participate in education or didn't after two warnings were actually terminated from their employment because it's like, we're making time for you to come do this. And we expect you to do it. So crucial for that to happen. So I don't know again what the confidential settlement was, but they really wanted to send that note to the hospital, please watch our patients. And we can accommodate them. That was part of the falls program. You can accommodate a patient to get up and walk around, just make sure they're safe to do it. That was the big issue. We hadn't kept an eye on our patient. What we documented didn't match with what should have occurred. So any further comments on what they would have or should have done with their patient? Yeah, I see one here that says possibly hire a sitter or virtual monitoring. Yes. Another one says, for one thing, if only dehydration was the issue, she should have improved rather than declined. With her declining mental status, say neuro consult and CT or MRI brain should have occurred. Neuro and safety check should have been instituted and family should have been informed. You guys need to work at that hospital. Absolutely. Yes, you picked up on it that she was declining. She wasn't getting better. And what happened? Now they talked about doing a post on her, but the family said, oh no, you're not touching our mom. You've messed with her enough. And because what they think might have happened, especially with her declining LOC, did she have a stroke? She has the history of TIA. She has the history of high blood pressure. Did she stroke out during that hospitalization and it wasn't caught? It could have been a silent one, who knows, but we didn't catch it. And you're right, seven days in and she's getting worse. Things aren't adding up here. The documentation didn't support that. So excellent. Everyone nailed it. Perfect. There's another comment here asking, I think about the previous case. I'm asking, was that one a lack of informed consent because of the wrong side? Okay, that was a shaky claim. I agree. It was lack of informed consent on the basis that had this patient known of the physician's litigation history, he would have chosen another physician. He wouldn't have agreed to go forward with that surgery. And that was not told to him. That was the basis of the claim. A shaky one, yeah. Yes, it was, but it was allowed to proceed. And again, the parents brought that claim, not the patient because they felt the patient didn't have the competence to make that decision at the time of his injury. So that's why the parents were allowed to go forward with that claim. Yeah, again, very shaky claim, but it was allowed to proceed. Yeah, a comment here saying, who is expected to know the litigation history of all providers? Yeah, exactly. And at one time they were looking in the state to add that to the requirements that a physician disclosed that to patients. Hey, by the way, here's my history of claims. I do have these, this was involved. It's like, oh my goodness, if that's the case, a lot of patients aren't gonna get surgery because somewhere along the line, there's a good chance a physician is going to have a lawsuit. That has since been rescinded from their board of medicine requirements for a physician because it was just, it was unrealistic to have that expectation that you go in and check it out. Usually what they said was, you know, hospitals, you need to be checking up on this when you do your credentialing and your privileging. And if you have someone that's got that history, that's where you need to work on it. Don't put that onus on a patient. That's not where they're, that's not what they're there for. That's your issue, medical board, medical staff and privileging and credentialing. All right, so these are good questions, thank you. All right, inaccurate documentation. This is the one. 82-year-old admitted for pneumonia, dehydration and weakness history of falling, left-sided weakness post-CBA. Admitted to a medical floor for IV antibiotics and hydration. Orders included a post-tolerated reposition every two hours in bed. So we have this patient, he came in about late in the afternoon. Low-grade fever, cough, bilateral lobe pneumonia, alert, some intermittent confusion, follows commands slowly but fully. Skin dry or turgor, redness to his coccyx area, skin intact, elbows are red, dry, skin intact. No other areas of redness or breakdown noted. So that's a fairly good assessment on admission. So here's the plan of care with our gentleman. They're gonna work with him to stay off his back. I want him up in the chair one hour every three hours while awake. It's reasonable. Keeping off his backside, turning him side to side. An RN is to assess the skin condition. Every shift, monitor those areas of concern. Elbows, heels, his entire back with every repositioning. This is day five that he's in. Over the next four days, he does get better, but he doesn't wanna be in the chair. And while he's in bed, he wiggles himself back to a supine position. Day five. Eight o'clock, he's in bed. He says, I'm not getting up. He is now combative. He doesn't need anything to try and get him up into the chair. IV is intact, infusing. He's repositioned onto his right side. Noon, patient's in bed. He's laying supine, repositioned now to his left side. Four hours have gone by. Shift change. No change in condition. IV continues, still refuses to be up in the chair. Another four hours, prepared for bedtime, propped to his right side, skin intact. Midnight, shift change. Prepares to be sleeping, skin intact, IV infusion. Four o'clock, sleeping, left undisturbed. Okay, so now we've got this entire day plus where he said, be off your back, be on your sides. Try to work with him. 8 a.m., shift change. He's assisted to bedside for the linen change. Now they noted red drainage. He's got a two by three inch breakdown on his coccyx, two to three open areas on his elbows, red one blistered, but intact. Physician noted, and now they get the decubit ordered for him. Not a pretty sight. For those of you who've seen it, you know how bad it can be. What are your concerns? How about that admission documentation? Was it sufficient to know about his skin condition? Yeah, he's got redness to the coccyx, okay? How big is it? What do we know about him being home? Care plan. Did it really address his needs? And what is meant by monitoring? One of those ambiguous terms. What do you mean monitor? How about actions to teak? If you do see something of concern, again, he won't stay off his back. Why is that? Does he forget that he's to stay on his side? Is it too uncomfortable to sleep on his side? No, he's a little bit older gentleman. Maybe it turns his hips and shoulders to lay on those sides. Is there something else maybe we should have done? Same with his resistance to being in chair. Why do you not wanna be in the chair? Does it bother you to sit up? Does it hurt your back? What is it? Are there other alternatives that could have come out? So here's some of the concerns with the documentation that you may wanna ask yourself. Was it accurate on day one? How about day five? Was it complete? Was there any reflection of that assessment? Did it reflect skin assessment? And blankly, was there an assessment of his skin at any time? Because again, all we see documented was refuses to be up, appears to be sleeping, turned to his side. That's about it. That's all we ever saw. Here were the nursing comments on it. Very concerned about, especially day five, by the time we get him. They don't believe the size of the cube could have increased as it did overnight. They're just not buying it. Any evidence of assessments, the area after day four? None. Checking the patient known area of concern only for hours? Is that really within the standard of care? Now we know we've got this breakdown started. We know he doesn't wanna stay off of his back. Okay, how's it looking back there? Because we know there was a problem when he came in. How's it looking now? Other investigation policy and procedures, the frequency, the content documentation requirements wasn't very clear. How often are you supposed to do that? Policy and procedures wound care. That should have been to cube care for full skin assessments in the area of concern, especially, and it was every two hours by policy and procedure. They did it every four. Night shift had one RN, three CNAs for the care. The CNAs were to get ahold of the nurse if they noted any change in that condition. And then the nurse was to document it. Now here, what they believe is one, did the CNAs really look at this person's backside? Did they turn on the light, reposition them, and look at it? Or what did they do? Or did they just turn him and move on? Was that even communicated to him? And the nurse, again, the nurse was to assess the patient's skin, entire back, every shift. And according to documentation, it didn't happen. Or if it did happen, it wasn't documented. After no more investigation, it learned the staff hadn't been doing it at all, hadn't been checking his back, just turning it. Nurse inappropriately relied upon the assistants to assess the condition, despite what the plan of care said. They did retraining, the verification, everything had been done for all staff. Two of them were put on probation. The patient had lengthy stay for wound care, and we did end up settling this in the mid-range. We were able to get that wound pretty well healed back up. It was a challenge, because he did finally say it hurts to lay on my left side. That's why I don't like to do it, and why I squirm onto my back, because it feels much more comfortable, and I can sleep. That's a valid issue with him. So what could we have done different to help him with that decubitus? All right, now it's our last case. This talks about communication between us, our providers. When a patient comes in after an MVA, triage nurse notes the chief complaint as neck pain, red flag. Assessment had tingling both arms when he moved his head, and documented it, but didn't tell the physician. Physicians documentation said, complaints of upper back pain, normal neck exam. Imaging, they did plain films of the thoracic spine, and head, and that was reassuring. 1045, he's on the stretcher. This is a nursing documentation. Headache, neck soreness, vitals, they're okay given his condition. Scrapes to abrasions, hands, forehead, able to move all extremities, so we're good. But he does say, you know, my arms feel funny. They tingle when I move my head side to side. And when I stop laying supine, like if I turn on my side, it hurts. 11 o'clock, he's quiet. He's on the cart, scalp abrasions, they still note those, minimal bleeding. He reports being rear-ended. He was the driver of the first car, and he estimated the speed to be about 55 miles an hour at impact. They're moving at that point in time. Still has upper back pain without radiation, neck exam normal, he can lift his arms to a shoulder height, grips are equal, moves everything equally. And now they're saying, oh yeah, that's right. So that's what the documentation of the physician said. So he's discharged home now. They go, okay, we can't do anything more for him. Take it easy, follow up with your PCP in three days. Well, the patient wakes up the next day and he can't move one arm. And he comes back to ER. Now they do a CT of his cervical spine, and they find an unstable fracture. Unfortunately, he ends up with permanent arm weakness because of it. Investigation, they found that the communication between the nurse and the physician simply didn't occur. And this was when referenced to the neck pain and the tingling. Sometimes it did occur when, you know, it was that the ER was very busy. So we know that's an ER and that happens. It was a major metropolitan area. This particular RN had two other patients. There was a history of poor communication with the nurses and especially this one and the other providers. Other staff on the day of this patient was a float nurse, one regular staff, five patients in between them. The other three, they were fairly stable. So they gave them to the float nurse. The nurse said, you know, that physician should read what I write. Patients may not tell the MD. Okay. The physician, I'm too busy to stop and read everything the nurse should have told me verbally. We can see where the interpersonal communications here is somewhat of an issue between these two. Let's talk about what's your assessments. And I want you to be the risk manager on this. What do you believe is your opinion? If you're the nurse manager, same question. Is there anything going on in this department? What's missing? What's your culture within that department? If you sit on peer review or you're part of a peer review committee, what would you offer to the docs? Who is and what is communicating with the nursing staff? What's the expectation for that communication? So keep these things in your mind because I want to show you what, again, they're telling trial lawyers. These are the plaintiff's counsel. The value of recognizing the difference between a brief note of a busy physician and the more time allowing leisurely, more explicit account of a nurse, look at that closer and have a more exposed encounter for any given patient. I would argue that if you're an ER nurse. When you're looking in the proper light, a nurse's notes may give you much more credence by a jury when confronted with a conflict reflecting significantly on the client's injury or the question of liability. Essentially what they're saying here, this nurse documented it. That physician should have looked at that documentation because that's a communication tool. And when you're busy, that's all sometimes you can rely on rather than getting a nurse pulled away from a patient who still needs them. So that's what they are telling the trial lawyers. Look at that documentation and was it communicated? What were the concerns here from an overall patient safety standpoint? Staffing. Did you have a qualified nurse to help the regular nurse, that float nurse? Was that individual qualified? Also the department communications, what was the expectation between the physician and the nurse? And then was there an escalation protocol? In other words, okay, this patient's having this issue. He came in with a neck injury and back injury, et cetera. Given the history of that accident, 55 miles an hour in your rear endage, you're going to have that retrograde movement of your head going forward and coming back. And that cervical spine is gonna take the beating on it. That really should have been vetted out more. And it wasn't, whether it's through the nurse or even the physician, because again, the physician discharged him based upon what the patient was telling him. He didn't look at the documentation. And again, no communication with the nurse and him. I want to talk briefly before I give you the outcome on that one. Staffing impact on outcomes. There are three studies that show it. More staffing, better outcomes. And this was the very first one back in 07 that showed that direct correlation. That happens to be what that looks like. Institute of Medicine. Staffing, nurse staffing is linked to safety. They also give some recommendations, limit the number they work, no mandatory overtime, and no more than 12 hours or 60 hours in a week. They noted a 30% increase, 38% actually, or three times the error rate when you do that. There are other areas that affect staffing. Medication error rate, UTIs, falls because nobody's there to help them. Pressure ulcers, gastric ulcers, readmission rates, codes, because again, not monitoring. We can't monitor the patient. We can't be in six places at once. And length of stay. This was from 2004. AHRQ from 08. There's actually a three-volume handbook that talk about nursing, and the chapter talks about staffing and quality of care. This outcome, it went to court, unfortunately. $9 million verdict in that case. The nurse's note documented the presence of neck pain at the initial visit, but there was absolutely no communication between the physician and the nurse. That was a critical item. And in fact, the reviewer looked at it, and when looking over the case, the nurse reviewer said, this nurse has a problem with her documentation, doesn't she? Because there's nowhere in here that she communicated that issue to the physician. And the nurse admitted, well, they're supposed to read it. That's not my job to tell them each and everything. And I'm thinking, yeah, it's a critical issue. That's your job. That's what you're there for. For the hospital, education for the nursing and medicine, how to improve our communication. How can we do that? And the expectations. Each service sat down and said, what do you expect or what would you want to have that physician know on these types of patients? And they listed like pediatrics, neonates, suspected head trauma, suspected spinal problems, anything. What would you expect to have them be able to communicate to that physician? Think of it as a critical value. And same for the physician. What do you want to know about those patients? And then they looked at alternative staffing options. In other words, how do we make sure we get qualified staff in here? Maybe we bring in another nurse to help balance it out between the other patients that are present, or if nothing else, support that qualified nurse, that one who has the experience, who is there. Maybe give them some help. And keeping an eye on the patient, monitoring, communicating with the physicians, whatever it happens to be. But to not have that communication, that's really what led to this issue with the patient. So any questions on that one? That is our last case. I see we're getting almost close to 90 minutes. So Lindsey, I'm gonna open it up and see if there's any questions or concerns with this or the other cases that we've covered. Perfect. Okay, I don't, oh, just here is one that says, how does zero-based staffing help with better staffing or better outcomes? That's a very good question. I wished I had an answer. A lot of that, it's also gonna depend on who are you? What is your, what kind of patients are you taking care of? Are you a level one trauma in a major metropolitan area? Or are you a level three trauma in somewhat of a residential area? Because that's going to be highly dependent upon who you have, what you have, and where you are. So I'm sorry, I don't have an answer for that one. Okay, on the previous case, never document appears or sleeping. We don't know that a person is sleeping. Yeah, that's a very excellent point. Appears, what do you mean they appear to be sleeping? Are they snoring or what? All you can do is saying eyes closed, not disturbed. Again, that was a case they were supposed to wake up. They were supposed to check that patient out and they didn't do it. So again, appears to be sleeping, we don't know that. We really don't. I know it was frustrating, especially when working in ICU. And those of you who've worked in ICU, we have issues with sleep deprivation with the patients because we're constantly waking them up to check on them and evaluate them and do things for them. And they get sleep deprived, which can affect their overall recovery. It's such a hard balance between really good care and helping them recover. And right now there's nothing out there to show that nice balance. It's patient by patient. We had it in CCU where we would have patients in there for two weeks sometimes because they were so ill. And finally, we just said, we've got to agree and talk to the physician and the family. And the patient said, we're gonna let you sleep tonight. We'll watch your monitor. We'll keep an eye on you, but we're not going to disturb you. And by George, he said it really made a difference the next morning when how much better he started to feel, one night of full night's sleep. I know I was a little off track, but just to show where do we over assess that patient? Where do we do that? Perfect. Okay, I don't see any other questions at this time. I'm gonna post some information for everybody in the chat. If y'all have any questions, y'all can go ahead and type those in as well. Great. And just some key takeaways for you. Look at your policy and procedures. What do you expect of your staff? Really, what do you want them to do? Explain those expectations and why it is so important. You may wanna just do a blanket audit for all units, but have that list of items that you're going to assess because that will vary according to your units and the type of patients. Maybe you wanna look at current staff to do those audience. Have a game with prizes if you want. One thing you don't wanna do is shame them. Maybe they just had a bad night and it can be something you can work on You've identified, okay, we got a gap here. We can fix that. And again, don't shame them by putting their documentation up on a wall and saying, how bad this is. Rather emphasize the positive. You've heard that so many times. Never, ever change the record. You can make an addendum, but check with your risk for guidance on that. So long after the fact and that gap, it's just gonna look bad, self-serving. Document for safe care. Don't make it a burden. I understand it's hard because so much depends on that documentation. And I noticed that there are some doctors now who are really starting to read it. I gotta hand it to them. Whether the medical schools have started to emphasize the importance of reading nursing documentation, I don't know, but some of them are doing it. And of course, be professional in what you do document. You just don't want it cropping up in a lawsuit and having to explain why did I make that unkind entry into their jousting, whatever you wanna call it. So thank you, everyone. Lindsay, thank you. I do believe, yes, I have. I wanted to list out the principles. That's how you would get to that. It's free that you can tap into. Lippincott, they also talk about nursing documentation. That's from August of 2023. So that's it. I don't have too many more. If there's another resource that I mentioned in there, let Lindsay know and I will get it over to Lindsay. Perfect. Thank you so much, Laura. I did just post information there for you all in the chat. So you will receive that email tomorrow morning. I know there was some questions about the recording and the slides. Another comment here saying great information. Thanking you so much. I know this is wonderful information that you'll want to possibly go back and review or possibly share with your team members. And so you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us And so those emails very often seem to get called on your spam quarantine junk folders. So if you don't see it in your inbox in the morning, please go back and check those additional folders. And then if it's still not there, and again, you'd just like to go back and access the reporting. We do record this. We have recorded this webinar as on demand. Maybe you can use that same Zoom link that you use to join the live presentation to also access the reporting. And then that recording will be available for 60 days from today's date. You will need to click on that Zoom link and type in your information for an email to come to us for approval of your reporting access request. And we do approve those very quickly, but we ask that you give us one business day to do those approvals. And then again, you'll have full access to the reporting for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented for us today. But that link is there now for you in the chat as well. And then also, if you're joining us as a member of the Georgia Hospital Association, pay special attention to that final link that will be in that email tomorrow morning. And that is a link to the survey that you'll need to complete in order to obtain your continuing education credit for today's session. If you're joining us as a member of a partner state hospital association, I do encourage you to reach out to your contact within your association to obtain information regarding continuing education credits as well. And as Laura mentioned, if you do have any additional questions, don't hesitate to reach out to us at education at gha.org. And we're happy to work with her to get those responses back to you, Laura. Always goes above and beyond and being so timely and thorough in her responses. And we just so greatly appreciate her for doing that and just seeing lots of wonderful comments here, Laura. So thank you so much for your time as always and sharing your information with us. And I hope you all have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

medical documentation

American Nurses Association

documentation principles

data protection

standardized terminology

objectivity in records

patient safety

miscommunication consequences

legal implications

professional environment

documentation quality

healthcare compliance