Nursing Home Documentation
Nursing home documentation is vital for many reasons. It is a basis for communication between healthcare professionals. State surveyors, insurers, and administrators use it to evaluate the level and quality of care provided. It is also a tool used to decide among various treatment options, to determine level of reimbursement for nursing services, and to determine the effectiveness of interventions provided. The resident's physical, mental, social, and spiritual condition is demonstrated through complete documentation.
All documentation regarding care and services given to each resident becomes part of the legal medical record. There is no way to prove care was provided without complete documentation. If a resident suffers an illness or injury and care was not completely and accurately documented (ex. pressure sores from lack of documentation of turning and repositioning), then it is doubtful quality care was completed, even though nursing staff may insist that such care was provided. The resident’s medical record is the main mechanism by which state surveyors, attorneys, and the attorney’s experts will evaluate the quality of care provided by the nursing home and its staff if episodes of suspected neglect or mistreatment occur.
Due to the demands in the nursing home setting to support that federal and state minimum care requirements are being met, the importance of complete and accurate documentation cannot be overemphasized. Unfortunately, many nurses and certified nursing assistants (CNA) do not understand the significance of documentation. Often times, due to the shortage of nursing home staff, the following may occur:
- Care is provided, but not documented.
- Care is not provided, and falsely documented as being completed.
- Care is both not completed and not documented.
CNA documentation is especially problematic. Often times due to short-staffing and heavy demands in completing resident care activities, CNAs do not document the care they provided until the end of an eight or twelve hour shift. It is very difficult to remember the care provided to 6-10 (or more) residents over the course of a shift. Documentation of care may be “best guess” and not always accurate, which may lead to negative healthcare consequences.
The following are mistakes that staff sometimes make in documentation:
- Documenting meal intake before meals occur
- Documenting medications were given prior to giving them
- Filling in check boxes on flow sheets quickly without thoroughly reading the information. By carelessly completing documentation without ensuring it is accurate and thorough, CNAs often chart on the wrong resident and on the wrong day. Some have even documented giving care to a resident when the resident was at the hospital or deceased!
- Having sloppy handwriting
- Failing to sign and date notes and flow sheets
- Using correction fluid for erasing mistakes; doing so makes surveyors, attorneys, and the attorney’s experts question whether the staff tried to change the record to “cover up” information that may reflect bad care.
- Failing to document changes in a resident's condition that may be significant. Such information may include:
- Mental status changes
- Abnormal vital signs
- Appetite changes
- Weight changes
- Changes in skin condition, such as bruises or red areas that may be the first sign of a pressure sore
- Changes in urinary or bowel elimination
- Complaints of pain
What are the consequences of poor documentation?
- Residents receive poor quality care that may lead to injuries, and even death.
- Nurses and CNAs do not receive information they need to provide high quality nursing care.
- Nursing supervisors do not have information needed to determine if care has been effective.
- The nursing home can be fined for lack of documentation by the State and may even suffer legal ramifications from lawsuits.
Meador, R., Schumacher, M., & Pillemer, K. (2003). The expert CNA’s illustrated guide to documentation. Clifton Park, NY: Delmar Learning.