Legal Implications of Nursing Documentation in Obstetrics

Margaret Rhone Wood, Ph.D., R.N.

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Overview of the Presentation

1. CNO Documentation Standards.2. Experts and their reviews.3. Documentation is evidence. What

documents are we talking about? 4. Sources of nursing standards.5. Sources of nursing liability.6. The role of the hospital and insurers.7. Summary and take-home message.

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Purposes of Nursing Documentation (CNO)

1. Communication2. Accountability for actions3. Legislative requirements4. Quality improvements5. Research6. Funding and resource management.

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Purposes of Documentation (CNPS)

Legal proof of health care provided: nursing documentation is relied upon by the courts as evidence of what was done or not done when a patient sues.

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Purposes of Documentation in Legal Proceedings

• To prove or disprove evidence of breach.• To draw conclusions or make inferences.• To prepare a statement of claim and

counterclaim.• To use as evidence at trial.• To provide to the experts for review and

analysis.

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The Medical Record

• Usually the focal point in litigation.

• The quality of the information in the medical record can influence the outcome of a legal action.

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Proof of the Standard of Care

Experts:• Provide an opinion on the standard of

care and whether or not it was met and caused harm.

• Provide an opinion on the adequacy of the hospital policies, protocols, procedures, guidelines.

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Expert Review

• Standard of Care [MD, RN].

• Causation (Did the breach or failure to meet the standard cause the harm?) [MD].

• Damages [OT/PT, CA, MD].

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CNO Documentation Standards

The nurse’s documentation provides a clear picture of the needs or goals of the client, the actions of the nurse, and the outcomes.

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CNO Documentation Standards

• Clear, concise, comprehensive.• Accurate, true, honest.• Reflective of observations.• Timely, chronological.• A complete record of nursing care

provided, including assessments, identification of health issues, a plan of care, implementation, and evaluation.

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CNO Documentation Standards

• Legible and non-erasable.• Permanent, retrievable.• Confidential.• Client-focused.• Completed using forms provided if

consistent with these standards.

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CNO Documentation Standards

• Document client preferences.• Document the implementation of the care

plan.• Document independent and collaborative

actions.• Document information reported to

another provider and the provider’s response.

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Documentation is Evidence

• The Plaintiff uses documentation to prove that the standard of care was not met [and harm was caused].

• The Defendant uses documentation to prove that the standard of care was met [or if not met, harm was not caused].

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The Legal Importance of Charting

• Recall of events over time is difficult.

• Timely, accurate records are essential in establishing the quality of care provided.

• Discrepancies, inaccuracies will discredit.

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What Documents May Be Used?

• Full chart: mother and baby. • Fetal monitor strips.• Policies, protocols, procedures, guidelines.• Précis of meetings held with the family.• Incident Reports. Personal Notes.• Any document not protected by the Quality

of Care Information and Protection Act, 2004 (QCIPA).

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“Prudent Nurse”

• Current maternity textbooks.• AWHONN: The Association of Women’s

Health, Obstetric and Neonatal Nursing.• CNO: The College of Nurses of Ontario.• SOGC: Society of Obstetricians and

Gynecologists of Canada• Protocols, Procedures, Policies, and

Guidelines of the Hospital (if current).

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The Clinical Picture

Anyone reviewing the chart must be able to see what transpired:

1. What happened2. To whom3. By whom4. When5. Why6. The result of what happened.

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Sources of Nursing Liability

• Failure to perform assessments.• Failure to recognize a change in patient

status.• Failure to notify MD.• Failure to follow policies and procedures.• Failure to document.• Failure to follow-up.

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The Hospital’s Responsibility

Public Hospitals Act: Public Interest: The quality of care & treatment of patients.

• Ensure proper charting is completed.

• Ensure departments have reasonable policies and clear standards of acceptable practice.

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Hospital Insurance

• Healthcare Professional Liability Insurance• Common claims involving nurses:

– Failure to monitor the patient– Failure to document

• Scant notes• Charting by exception and focus notes poorly

understood and inconsistently applied.• Not reading other providers’ notes. • Checklists used in place of progress notes.

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SummaryTake-Home Message

• Obligation to chart appropriately.– Important in the health care context.– Important in the legal context.

References• Canadian Nurses Protective Society. Quality Documentation. https://ben.cnps.ca/

• College of Nurses of Ontario, (2009). Practice Standard: Documentation, Revised 2008). Publication No.: 41001 http://www.cno.org/globalassets/docs/prac/41001_documentation.pdf

• Ontario Ministry of Health and Long Term Care (2015). Quality of Care Information Protection Act, 2004. http://www.health.gov.on.ca/en/common/legislation/qcipa

• Society of Obstetricians and Gynecologists, (2007). Fetal health Surveillance: antepartum and intrapartum Consensus Guideline. http://sogc.org/guidelines/fetal-health-surveillance-antepartum-and-intrapartum-consensus-guideline/

• Supreme Court of Canada. Joseph Brant Memorial Hospital v. Koziol, [1978] 1 S.C.R. 491, Date: 1977-05-17. Joseph Brant Memorial Hospital and Nurse G. Malette (Plaintiffs) Appellants; and Katherine Koziol and Joseph Koziol, by Suggestion (Defendants) Respondents; and Terrance L. Jeffries Respondent. 1977: February 23, 24; 1977: May 17. Present: Laskin C.J. and Martland, Judson, Ritchie, Spence, Pigeon, Dickson, Beetz and de Grandpré JJ. On Appeal from the Court of Appeal for Ontario.