Kammie Monarch: Good afternoon, everyone. Thank you for joining us. My name is Kammie Monarch. I'm the Chief Nurse Executive at San Juan Regional Medical Center, and I'm just delighted to have Rachel Timmerman join us. Rachel, would you introduce yourself to the audience?

Rachel Timmerman: Hi, everybody. I'm Rachel Timmerman. I've been with the organization since 2006. I'm a registered nurse, and I'm currently acting as your Patient Experience Manager here at the hospital and San Juan Health Partners.

Kammie Monarch: Rachel and I were in a committee meeting at one point recently where we were talking about the importance of documentation and that sort of thing. And I do a presentation focused on documentation during nurse residency. And the story that Rachel told about documentation in her own clinical experience, I thought, was powerful. So, I really wanted Rachel to be able to share her story with you, hoping that it would be compelling and thoughtful and it would inform the documentation that we're doing every day at the bedside of patients. So, Rachel?

Rachel Timmerman: Thank you, Kammie. And thank you for inviting me. I want to describe a deposition that I gave back in May of 2019 where I was questioned by a lawyer about my charting practices and particularly the fall risk assessment related to a fall that occurred on a patient that I was caring for in April of 2017 on the surgical floor.

I'm talking out loud about this, because I care about protecting our patients, our caregivers, all of you out there, and our organization. So, I'm going to give you guys a summary of the key points from the deposition.

First, it was really about charting practices. The lawyer asked me about the famous phrase, "Not written, not done," which is a common expression in healthcare and other settings. It refers to the idea that if something isn't documented, written down in the patient's chart or recorded, then it didn't happen, or it cannot be legally or professionally acknowledged as having occurred. This is a critical concept in healthcare documentation because proper charting helps ensure that care provided is legally supported and traceable.

Secondly, this case was related to a fall and a heavy focus was on the fall assessment. The lawyer asked me if I recalled noting the results of the fall risk assessment in the patient's chart. The suggestions they were focusing on whether or not the fall risk assessment was properly documented at the time, which would be more important in understanding whether proper precautions were taken regarding the patient's fall risk. The lawyer also questioned me about my practice of adding addendums to my nursing notes. I explained that an addendum is typically a note added to a chart after the initial entry was made, usually to clarify, update, or correct information in their original documentation.

So, reflecting back on my deposition, some potential points that the lawyer might have been trying to explore regarding my documentation practice was able to clarify those addendums in my practice, whether I commonly use them, under what circumstances, and how I documented changes in my patient's condition. For instance, my practice, I always added nursing notes throughout my shift, and I would an addendum to my oncoming shift note. I would add my mid shift note and an end of shift note. I wanted to paint the picture for doctors and following nurses so that they could have a clear picture and provide the best care that they could. Never did I thought that these notes and these addendums would end up in the hands of lawyers.

Another key point that the lawyer was searching in my charting was consistency and accuracy. Questions were aimed at determining if my documentation was consistent, timely, and accurate. So adding addendums raised questions about whether the original note was incomplete or there was any errors or omissions that needed correction later on. The lawyer was focusing on whether this was done to correct mistakes or really improve the quality of my charting. From a legal standpoint, the lawyer may want to understand whether my use of addendums was consistent with proper documentation practices. If an addendum was added after a significant event like a fall or an assessment, they might be investigating that if the addition was made timely and whether it was properly documented within the correct time frame. The impact on the case was that the lawyer was really exploring that if my documentation was completed timely and it affected the credibility of my documentation. In legal settings, anything added after the fact could be scrutinized to determine if it was the attempt to cover up or modify my previous notes.

As healthcare professionals, our charting practices speak for us as we are vulnerable to situations that we may not be able to control, but must prove we followed best practices to keep our patients safe. Following standards of care not only protect our patients, but it protects our license that we professionally work hard to obtain and inspire to serve our community.

In healthcare, documentation isn't just a clerical task. It's a key point of clinical practices that serves to safeguard our patients, uphold our professional standards and protect us. Our passion for following best practices and ensuring the safety of our patients is vital in maintaining the trust and credibility of our profession and with our community.

So really, in summary, at the end of that deposition, it really stood out how important charting practices are to protect yourself and your patients and the organization.

Charting has to be done timely and it has to be done in full. It's important that we complete our nursing notes as required by policy for the organization, and that they tell the story for the next caregiver that's coming to provide care to the patient.

Kammie Monarch: Thank you so much, Rachel, for your story. It just illustrates how important our documentation is every moment of every day in an inpatient setting or other care setting for that matter. And just attention to documenting your assessment of patients, changes in that assessment, interventions that are done and then the patient's response to those interventions are just imperative for us to be able to convey what at the bedside we're doing in patients to maintain their path to healing or what we've done to try to prevent deterioration when and if that occurs as well.

So, thank you for telling your story. I hope it has been interesting for you to hear this and that it informs the documentation that you'll be engaging in today, tomorrow, and the next day.

Rachel Timmerman: Thank you, Kammie.