Problematic Areas Where Gaps in Documentation Occur

Abnormal vital signs.  A significant deviation from what is considered to the patient’s normal requires an entry detailing what is being done about it.  For example, deviations may be fever, elevated BP, or slow respiratory rate.  If your response is to monitor the patient more closely, then write that in the medical record followed by the response of the patient improving or deteriorating or condition is labile.  If your response is to consult with the physician, record the time you placed the call or initiated the page, the physician’s response and orders received were carried out.  Sometimes you may not be able to reach the physician initially.  In this case, note the time you received the return call; the time you called for a second attempt; or the time you contacted someone else (perhaps initiating the chain of command).

When a patient codes.  Unexpected bad outcomes are frequently the motivation for family member initiating a lawsuit.  The plaintiff’s attorney will more than likely argue that monitoring of the patient was inadequate and the interventions were not timely or just too late.  Documenting what happened during a code or other emergency situation is crucial, yet these situations are precisely when entries in the medical records are incomplete or short creating gaps in the story line.  Avoid these gaps by using the code sheets provided by your facility; designate a scribe to assure the documentation is kept current during the crisis.  Following the emergency or crisis event, check the entries for completeness.  Include the disposition of the patient following the resuscitative efforts:  to the ICU, to the OR.

A patient is transferred.  Regardless whether a patient moves from a high level of acuity to a lower level of acuity or vice versa, or even from one medical floor to another of the same acuity level, a patient assessment is warranted by the receiving nurse.  It is imperative the condition of the patient is recorded upon arrival to the floor and when you assumed care.  This is also true when you are transferred the care of the patient to another nurse, the condition of the patient must be recorded indicating what the patient was last like while under your care. 

Have you discovered areas where you have found gaps in the ongoing care of patients?  There are many areas that I have not expanded on.  Invite me to expand on your areas of concern to avoid vulnerabilities.