The variation in electronic health records leaves plenty of room for healthcare providers to document patient care. Some electronic health records provide many options for capturing patient care, while others provide very few options, and both are inherently notorious for not capturing enough patient care necessary to demonstrate that a standard of care has been met.

An example of documentation that is frequently seen in medical records and often presented as a problem in court involves skin lesions. Prevention of skin lesions essentially requires that patients who cannot adjust their position be turned every two hours. According to the National Pressure Advisory Panel, many factors are considered when evaluating tissue injury, but the first and foremost intervention for all patients, regardless of “other factors,” is to convert patients. When a tissue lesion (pressure ulcer) develops, Stage II, Stage III, Stage IV, or suspected deep tissue lesion, scrutiny of care will include proof that the patient was, at a minimum, rotated to approach the standard of care for wound prevention.

Nursing negligence can be alleged for not turning the patient every two hours. Additionally, if the clinical history does not show that the nursing care plan includes an actual or potential problem that addresses impaired skin integrity, it is assumed that patient turning was not performed. If a wound develops, it is possible that a correlation can be made between the fact that the nurses did not turn the patient and it contributed to the skin breakdown.

When the medical history clearly demonstrates that the patient was turned every two hours and still developed progressive wounds, then “other physical factors” are considered to be significantly contributing. If the other physical factors do not exist, then the documentation can be considered a falsified cartography. Other physical factors include, but are not limited to: laboratory results, diabetes, coronary artery disease, previous surgeries, age, infection, etc.

Examples of when care has not been documented and caused additional scrutiny of care include:

• Raised bed head. Elevation recorded with specific grades is important when care involves aspiration precautions, limitation of hemodynamic or pure measures.

• Response to drug titration in a critical care area. Medication titration is expected to occur until the desired effect is achieved, particularly when orders are written in a protocol format. Medication management recorded in the medical record should reflect the appropriate clinical judgment of the nurse.

• Fall prevention interventions. It is not enough to simply register or mark: fall prevention protocol implemented. If a patient falls on their shift, will the records show that what was stated in the protocol was done to prevent the fall? Be specific about the interventions used when caring for patients determined to be at increased risk of injury.

Medical record entries must be factual, accurate, complete, and timely. Use the FACTS rule. It is very easy to remember.

FACTUAL means that there must be enough factual detail for the story describing the patient’s care to be clear. Facts are clinical findings that a nurse knows to be true. The facts can be laboratory results, clinical evaluation, medications, vital signs and could also mean what the patient says. Put what a patient says in “quotes.” First-hand knowledge is another way to determine what to hire. The best practice is to only plot what is known to be true. An exception to this practice is during a crisis intervention when the situation uses a scribe as it might during a code or rapid response. The scribe records as events unfold and documentation is reviewed for accuracy after the patient is stabilized by the healthcare team.

ACCURATE means that the facts must be recorded correctly. Laboratories must be entered accurately if not crossed through an electronic health record portal system. Movement of a single decimal point when recording an administered medication may indicate that the administered dose was 10 times or even 100 times the prescribed dose. Imagine if a record reflected that a nurse administered 10mg of Atropine instead of 1mg. How would this error be defended if a catastrophic outcome appears to be related to medication error?

COMPLETE medical record entries are thorough entries. Don’t leave the reader guessing about the care provided to the patient. Verify the integrity of medical record entries using: “OPQRST”.

“O” is for start.

“P” is for precipitating or aggravating factors.

“Q” is for quality or quantity

“R” is for radiate

“S” is for situation

“T” is for time (time of day)

The final term, TIMELY. Medical record entries are expected to be entered at the same time. All it means is plotting as soon as possible after the events occur. Timely in a high-acuity setting is not the same as timely in a lower level of care, including long-term care settings. The higher the acuity level; more entries regarding patient care are expected to be recorded. A lower level of acuity will have fewer commands, fewer interventions, fewer interactions, which equates to fewer inputs representing attention given. The frequency of entries should be adjusted according to facility policies and the acuity level of the patient.