Road blocks to timely documentation
Six months ago, after working for 15 years as a rural home care registered nurse, Ricco resigned his full time position to work casual with this same home care office. Now Ricco typically works two or three evening or weekend shifts per month, depending on his availability. These shifts have one registered nurse scheduled as the clients seen are those requiring nursing care at a specific time, or they cannot wait until the next weekday to be seen. Over the last month the home care program has implemented an electronic health record (EHR) where all documentation is completed. Ricco has had four weeks of training on this system, but still finds it complex and difficult to use.
Ricco’s shift starts at 4 p.m., and he has four clients to visit. It is snowing heavily this particular evening, but Ricco is comfortable driving on country roads through snowy conditions. The RN working earlier today has already organized Ricco’s evening because some visits are time sensitive. All Ricco needs to do before leaving the office is map out his driving route.
After providing nursing care for his first client, he sets up his laptop with the internet stick supplied by his employer to access the EHR. He tries to log on, but can’t connect to the EHR. He makes three attempts to log on with no success. Ricco is growing concerned as his second appointment is a client who was discharged from the hospital earlier today diagnosed with diabetes and requiring insulin. Ricco is to administer this client’s evening dose of insulin at 5:30 p.m. as well as provide some diabetic teaching. This second client is a 20 minute drive from his current location.
Ricco considers what he should do next in order to meet CARNA’s practice standard of responsibility and accountability as well as CARNA’s documentation standard: “Nurses document the nursing care they provided accurately and in a timely, factual, complete and confidential manner”.
Option 1: Return to the office
Ricco drives 40 minutes back to the office to document. In this option he demonstrates his accountability as an RN by documenting his assessment, nursing care and teaching provided as close to the time of care as possible. While in the office, Ricco consults employer policy to determine if he is required to complete an incident report (Reporting and Learning System for Patient Safety [RLS] report) related to the inability to log on to the EHR.
However, now he may be late for the second time sensitive visit and may also impact the remainder of the scheduled visits.
Option 2: Move on to the next client
Ricco drives to visit the next client who requires insulin at 5:30p.m. and arrives a little early. When he pulls up to this client’s home he considers trying to log into the EHR to document his previous visit. He assesses this rural farm yard and determines that there is nobody outside who could potentially see the computer screen so feels that he would not be breaching client confidentiality. Ricco logs on again and successfully accesses the first client’s EHR.
After consulting employer policy to determine if his documentation should be recorded as a late entry, Ricco completes his documentation. Ricco will need to continually assess his surroundings for potential breaches of confidentiality. If a risk exists, Ricco would need to log off the EHR and document when he can ensure that the client’s information is safeguarded.
Ricco then visits his second client on schedule.
In this option, Ricco demonstrates his accountability as an RN by documenting his assessment, nursing care and teaching provided as close to the time of care as possible. However, had he not been able to access the EHR from the new location, other health-care providers would not have complete information about the care Ricco provided.
Option 3: Contact the central home care office
While sitting in his parked vehicle outside his first client’s home, Ricco contacts the central home care program office. This centre receives all client related calls from all areas after hours.
He informs the RN at the central office that he is at a client’s home and that he is not able to connect to the EHR. He tells them that he will document when he returns to the office after he completes all of his visits. He knows his employers policy on late-entry documentation.
Ricco demonstrates his accountability and responsibility by trying to update client information. He recognizes the potential risk for the client and other health care providers who may have to make decisions without having complete information about the care provided. Ricco understands that RNs in the central office cannot enter data into the client’s EHR on his behalf as indicated in CARNA’s Documentation Standards for Regulated Members.
Option 4: Use paper-based documentation
Ricco’s employer policy states that if he is unable to document in the EHR, he can document on a paper nurses’ note, then scan the document at the end of his shift and add the scanned document to the EHR.
In this option, Ricco demonstrates his accountability as an RN by documenting his assessment, nursing care, and teaching he provided as close to the time of care as possible. However, even though Ricco has documented the care provided in a timely manner, other health-care providers will not have access to this information until Ricco returns to the office and is able to scan the nurses’ note and add it to the EHR.
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.