Wouldn’t it be nice if you could see patients without worrying about documentation? I often lament that box-checking is a soul-sucking part of my job as a nurse practitioner. But, documentation is a must for NPs and has its benefits as part of patient care (i.e. remembering where you left off at a follow-up visit). Protecting ourselves legally is, of course, another reason charting is an essential part of the patient visit. Unfortunately, as nurse practitioners, we’re often in a hurry and are prone to some easy-to-remedy documentation errors. Where are your charts falling short?
1. Inconsistencies Between the HPI and ROS
The HPI and ROS sections of your chart can be pretty repetitive. So, the temptation is to rush through the string of checkboxes in the ROS once you’ve spent a few moments typing out your HPI. But, what if you get interrupted in the middle of completing documentation and don’t remember the conversation with the patient as well when you sit back down at your computer?
I’ve caught myself countless times with inconsistencies between the HPI and ROS. One section of the patient’s chart says the cough is productive, the other does not. One section states the patient has vomiting, the other just nausea. This seems simple enough to get correct, but as a nurse practitioner you’re busy and constantly pulled from task-to-task. Inevitably, sometimes details and your memory slide. So, scan each chart briefly for HPI-ROS inconsistencies before hitting the “save” button.
2. Inconsistencies Between Your Note and the Nursing Note
This one’s a biggie if you ask me. In the emergency department where I work, as in many healthcare facilities, a nurse or medical assistant inputs initial patient data including things like the chief complaint and possibly other nursing notes related to the HPI. The screen I view when completing patient documentation doesn’t show the entirety of these nursing notes paving the way for massive inconsistencies. I’ve seen plenty of instances where the nurse’s and my story don’t match up. Maybe the patient tells the nurse he/she does have a fever but informs me he/she is febrile. Or, maybe the patient confides in the nurse a piece of related medical history that I miss in the nursing note and neglect to take into account in my treatment plan.
Whatever the scenario, the notes nurses and other clinic staff place in the medical chart must match up to your documentation as a nurse practitioner. The chart must tell a consistent and reliable story. As a NP, you must read then edit and/or comment on these notes if necessary.
3. Inconsistencies Between the Medication List and Medical History
We’ve all been there – looking at a chart that states “no medical history” paired with a med list including “Coumadin”. Obviously, there’s a story there and it probably involves the patient having a medical history. Don’t let this escape you. If your care is ever called into question in court and inconsistencies this obvious exist, a jury won’t look favorably on your competency as a nurse practitioner (these 5 CYA Documentation Tips will also help). Take the time to scan the med list and medical history to make sure they match up. If they don’t, get answers.
4. Inconsistencies Between Chief Complaint and Physical Exam
One of my pet peeves as a nurse practitioner is when the patient adds an “oh, by the way…” at the end of the visit. Usually the add-on complaint is something trivial, but it requires that I go back into each section of the document and include information about this complaint. A diagnosis code for the complaint without documentation throughout the chart to back it up won’t meet expectations. Make sure your physical exam documentation touches on each area pertinent to each of the chief complaint(s).
If you, too, fall into the “If I have to write another chart about [insert common medical condition here], I’m going to throw my computer monitor out the window…that is if I actually had a window and didn’t work in this dingy office, anyway…” camp, I’ve been there. But, taking the time to be thorough in your documentation is well worth the effort. Documentation sets the stage for quality patient care now and in the future and also helps protect you legally. So, check your charts for these common inconsistencies.
Where do you struggle when it comes to documentation?
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