In Nursing Standard of Care Guidelines: Why a blank or incomplete medical record suggests conduct that falls below the standard of care, attorney Kristin Miller answers the question “Why does a blank or incomplete medical record indicate a likelihood of nursing conduct that falls below the standard of care?”
“Nurses are required to routinely conduct assessments and reassessments, and they are required to document all of their findings in the patient’s medical record. A blank or sparsely filled in medical record at a time when the patient is receiving intensive care is a strong indicator of below standard conduct by the nursing staff.” Says Gayle Nash with Nash Legal Nurse Consulting, and a Chief Nursing Officer with twenty-seven years of executive nursing leadership experience.
A myriad of patient care considerations go into each patient assessment and reassessment. Nash preaches that a skilled nurse performing their work pursuant to standard of care will practice due diligence in their charting practices thoroughly performing as well as documenting each assessment and reassessment. The medical record, after all, is the patient care fingerprint indicating both the patient’s health status as well as how the nurses are performing and completing their patient rounds. A sparsely complete medical record should be investigated as a possible indicator of below standard nursing conduct.
“A properly charted medical record pursuant to standard of care will be complete,”
explains Nash. “We train our newly registered nurses to practice under the principle that any information left off the medical record will be interpreted as work not done.”
Complete charting on a head to toe assessment requires documenting a substantial amount of information. For example, if a patient presents to the hospital with pressure ulcers, a nurse has a duty to conduct a thorough assessment. Documenting on the medical record that a pressure ulcer exists is not enough to comport with standards of care. The nurse attending that patient must also document the ulcer location, size,
degree of severity or stage, any healing of the ulcer, odor or dying tissue, any drainage,
presence of undermining tunneling tracts, color, and temperature. The nurse is also required to conduct timely reassessments to monitor changes of that ulcer and the patient’s overall health condition while under that nurse’s care.
Q: Where the medical record is blank or incomplete, why should leadership and clinical experience be a hiring factor in the nurse expert’s qualifications?
Identifying where a medical record is missing critical patient information that points to below standard conduct requires hiring the right expert witness.
Nash urges Attorneys in need of an expert report on a sparsely complete medical record to consider hiring experts with leadership experience. Nurses in a management role are more likely to identify where the incomplete record points to issues in the hospital’s chain of command.
“Hospitals operate under a series of complex command chains. Nursing Directors are held accountable for all work not completed, and as such, make routine reviews of nurse charting and notes documented. Nursing Directors are also expected to know the standard of care guidelines set by accrediting organizations such as the Centers for Medicaid and Medicare and The Joint Commission.” A Nursing Director will, therefore,
have more experience identifying where the medical record is missing critical patient information.
Lastly, a nursing expert witness hired to review medical records will be expected to know where the medical record indicates below standard conduct, missing assessments or otherwise, for all nursing care provided. Because much of the charting and documenting requirements are learned on the job, Nash recommends hiring experts with actual clinical experience in the health care department most applicable to the case.
Kristin Miller, JD