Nurse Charting in the Correctional Health Care Setting- Part 1

Written by: Beth Boone, Esq.

There are differences in how a patient’s care and treatment is documented in the wide variety of settings in which health care providers practice. For example, a private practice neurology office may document with references to applicable insurance and billing codes, and use language that will allow an insurance carrier to recognize and compensate the providers for the visits and services they perform. As a defense attorney representing a wide variety of health care providers in many different settings, I am frequently asked about charting, including documentation in forms, electronic records and paper charts alike, and the details that should or should not be noted. Specific to the correctional setting, there is generally not insurance billing codes or reimbursement language. We also see nurses often providing the majority of routine services and usually having more daily contact with the patients. Due to the large role that nurses play in delivery of health care in the correctional setting, proper charting to fully reflect the hard work and dedication that these individuals perform daily is key.

Part 1 of the series of blogs regarding your charting starts with a review of the forms and documents you use daily. Medical record documentation is made to provide an accurate history that supports the care and treatment the patient received, correct? So, the inverse is that an accurate history would require sufficient documentation. If there is a form to complete- i.e. receiving screening- complete the entire form. Address any “boxes” or line entries with a N/A or other notation that evidences you have reviewed and considered that specific entry rather than just leaving it blank. Why? If you leave it blank and it is a form commonly used, the presumption is that you did not complete it. The same premise goes for date and signature lines- if there is a proper place to sign and date, do so. Unsigned and undated records always lead plaintiff attorneys to presume there is also insufficient documentation and data, and to further extrapolate that the patient’s records are just unauthenticated. In other words, empty spaces on forms- boxes, drop-downs with auto fill options, description lines, signature and date lines- lead the plaintiff attorney to assume you just did not provide that care and treatment. In Georgia, with a two-year statute of limitation for professional negligence, the odds of you specifically remembering why you did not sign that particular progress note when served 23 months later with a lawsuit are generally pretty slim. Bottom line- complete every portion of that form, address every line and show that it was indeed considered.

Try to be as accurate and descriptive as possible in your language, albeit in a nonjudgmental, factual manner. Charting that the patient complained about pain for the 27th day in a row but refused all over the counter medications and attempted physical examinations and then specifically requested Oxycodone adequately documents the situation. Documenting that the patient is obviously drug seeking, malingering and has no known diagnoses that would cause pain shows clear frustration and a presumed predisposed mindset that may allow an independent reviewer to assume you just refused to provide care, even if you listened patiently to the complaints for each of the 27 days. The attorneys that represent you know how hard you work. Shouldn’t the chart reflect your dedication and professionalism you show daily?

Finally, the chart is a medical record of care and treatment that is generally kept contemporaneously. While late entries are sometimes necessary, the appearance of a chart being altered is difficult to defend in litigation. While it may be as innocent as being confused about the date, when it is changed multiple times in the same chart, the examination at your deposition can be excruciating. Would a new note be easier that crossing out 8 pages of incorrect date and time? Or wouldn’t a final proofing of that entry prior to hitting the submission button be worth it?

We will continue to explore nurse charting in the correctional health care setting on the HBS Correctional Healthcare Blog. Stay tuned for Part II…