Staying Late to Chart: Is This Legal?

Question

Many nurses are unable to finish computer documentation until after the end of their shift, either on overtime or even on their own time. Is such documentation legal? What can be done about this situation?

Response from Carolyn Buppert, NP, JD Attorney, Law Office of Carolyn Buppert P.C., Bethesda, Maryland

The nurse who posed this question to Medscape describes a couple of documentation issues with potential legal ramifications:

"I work at a hospital where the nurses are expected to document what is happening with each patient every 2 hours. The computer system purchased by the hospital is so difficult that most nurses are either working overtime to complete the required charting, or are punching out and staying to finish charting on their own time. Some of us are being challenged about our overtime, but the nurses who are working on their own time could get into trouble for Health Insurance Portability and Accountability Act (HIPAA) violations, or worse. For example, what if the patient crashes or dies at the same time that the off-duty RN is charting that the patient has good vital signs and is alert and oriented? The computer documents the time that the nurse inputs the data. The computer system was not chosen with the input of the staff nurses who are using it. What can be done in a situation like this?"

Talk with the information technology (IT) contact for your department, as well as your supervisors. You make an excellent point that when a nurse's documentation is not reasonably contemporaneous with his or her patient assessment, the hospital is at risk if the patient has a bad outcome and sues. The standard is that documentation be completed within 1 hour of making an assessment or administering a treatment, unless an order calls for very frequent assessments or treatments or unless hospital policy states otherwise. If the documentation isn't timely, a plaintiff's attorney is likely to argue that the documentation isn't credible, which hurts the hospital's defense if the hospital is sued.

Most nurses chart after their initial rounds, sometime during the shift, when a patient's status changes, and again at the end of the shift. The end-of-shift charting could be brief if there aren't many changes in the patient's status during the day. Given that some nurses are fast writers and some are slow, that some patients are more complicated than others, that some nurses are more experienced than others with electronic charting, and that some software programs are better or easier to use than others, it is difficult to judge just how long documentation "should" take.

One question that must be considered is whether the new computer system is inherently cumbersome or whether the users are on the upswing of a learning curve, meaning that things will get better as time goes on. Usually, it takes healthcare providers about a year to become efficient in their use of electronic medical records; during that year, ideally, there is dialogue between the clinicians and the IT staff about problems and inefficiencies

If the system is inherently cumbersome, then I suspect that not only nurses, but also all of the other healthcare providers who use it, are frustrated. In that case, you should request a meeting with administrators and address the issues. Ask that other types of providers who use the system be invited to attend. Prepare for the meeting by listing your frustrations with the electronic medical record software. State what you need changed. Be specific. Ask for resolution of the problems.

Meanwhile, the administration needs to be consistent on the issue of overtime. If a nurse cannot reasonably finish his or her patient care and documentation during the shift hours, then overtime is appropriate. A competent supervisor should have a sense, over time, of whether specific nurses legitimately and reasonably need to stay late. If so, then staffing and assignments should be adjusted so that the nurses can finish on time, or overtime should be paid. Or, if specific nurses aren't spending their shift-time wisely, then the supervisors should conduct counseling or training about how to be more efficient.

I am hearing many complaints about hospital electronic medical record systems being cumbersome and inflexible. I believe that kinks can be worked out, but only if all of the parties take the time to communicate.

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Cite this: Staying Late to Chart: Is This Legal? - Medscape - Jun 04, 2013.