A paper or electronic patient health care information record serves two major purposes: communicating information both within and outside the practice and creating written history in the event of later questions or challenges. Complete, accurate, and legible health care information records document all phases of medical treatment, including the care plan, laboratory and diagnostic testing, procedures performed, and medication provided.
The new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) analyzed 287 closed professional liability claims against nurse practitioners (claims that resulted in an indemnity payment of $10,000 or greater) over a 5-year period. The report’s analysis revealed that the majority of claims against NPs resulted from an alleged failure involving core competencies, and demonstrates that nurse practitioners are responsible for reviewing, following up on, and documenting the results of appropriate tests and consultations in a timely manner.
The following general principles of documentation can help the practice maintain a consistent, professional patient health care information record:
Ensure that hard-copy notes are legible and written and signed in ink, and also that they include the date and time of entry.
Avoid subjective comments about the patient or other health care providers.
Correct errors clearly by drawing a single line through the entry to be changed.
Sign and date the correction, as well as the notation giving the reason for the change.
Do not erase or obliterate notes in any way. Erasing or using correction fluid or black markers on notes may suggest an attempt to purposefully conceal an error in patient care.
Document actions and patient discussions as soon as possible after the event. If it is necessary to make a late entry, the entry should include the date and time, along with the statement, “late entry for ______” (i.e., the date the entry should have been made).
When dictating notes, include all vital information, such as date of dictation and transcription. Sign transcriptions and write the date of approval or review.
Never alter a record or write a late entry after a claim has been filed, as this may seriously compromise legal defense.
Develop a list of approved abbreviations for documentation purposes. Review and revise the list as necessary and at least annually. In addition, maintain a list of error-prone abbreviations that should never be used, such as this one from the Institute for Safe Medication Practices.
If using a form, complete every field. Do not leave any lines blank.
Furthermore, to help nurse practitioners avoid this segment of risk, nurses should ensure their practice has a written policy governing documentation issues, and all staff members are trained in proper documentation practices. The policy should address, among other issues: health care information record contents, patient confidentiality, release and retention of patient health care information records, and general documentation guidelines.
And while rare events may be difficult to prevent, nurse practitioners can glean lessons from the experiences of their colleagues to help evaluate and enhance their own patient safety and risk management practices.
Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.
According to the American Association of Nurse Practitioners, there are more than 234,000 nurse practitioners (NPs) licensed in the U.S. today. As health care delivery has continued to evolve, many Americans are using NPs for much of their health care needs, making nurse practitioners a critical component of the modern system. This growth in demand and responsibility has also increased and evolved the many risks NPs face in their work environments. The new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) took a deeper look at those risks by analyzing 287 closed professional liability claims against nurse practitioners (claims that resulted in an indemnity payment of $10,000 or greater) over a 5-year period. Study results found the average total incurred payment per claim was $240,471, and indicated that while the number of nurse practitioner claims have been relatively stable over the past five years (2012-2016), the average indemnity payment has increased at least 2% annually since 2012.
Current Liability Patterns and Trends
Nurse Practitioner Claim Report insights show that the majority of claims against NPs developed from a failure involving core competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs were found most frequently.
These claims demonstrate that nurse practitioners are responsible for reviewing, following up on, and documenting the results of appropriate tests and consultations in a timely manner, as well as properly evaluating each patient prior to prescribing medications.
Other findings from the report revealed:
The three specialties with the highest average paid indemnities were neonatal, women’s health (obstetrics), and emergency medicine.
The highest percentage of closed claims occurred in the adult medical/primary care, family practice, behavioral health, and gerontology specialties.
The health care delivery settings that experienced the greatest number of claims were physician office practices, nurse practitioner office practices, and aging service facility, skilled nursing.
Both the frequency and severity of nurse practitioner office practice setting closed claims have increased significantly. In 2012, this setting accounted for 7.0% of the closed claims, with an average paid indemnity of $45,750. In 2017, this setting accounts for 16.4% of the closed claims, with an average paid indemnity of $158,611- three times greater than in the 2012 report.
Five allegation categories accounted for 95.0% of all the closed claims in the analysis: diagnosis, medication prescribing, treatment and care management, assessment, and scope of practice. Diagnosis-related claims had the highest percentage of closed claims, accounting for 32.8% of all closed claims and with an average paid indemnity of $283,263 per claim.
Current License Protection Patterns and Trends
Different from a professional liability claim, an action taken against a nurse practitioner’s license to practice may or may not involve allegations related to patient care and treatment provided by the nurse practitioner. The Nurse Practitioner Claim Report also evaluated this particular risk area, analyzing 404 reported license protection claims affecting CNA/NSO-insured NPs.
Of the closed claims, 240 resulted in a license defense cost in which legal counsel defended nurse practitioners against allegations that could potentially have led to license revocation. The allegation classes with the highest percentage of license protection defense paid claims were medication prescribing/management (27.1%), scope of practice (22.1%), treatment and care management (13.3%), and professional conduct (8.8%). The average payment – comprising legal expenses, associated travel costs, and wage loss reimbursable under the policy – was $5,987. License defense paid claims involved both medical and non-medical regulatory board complaints against nurse practitioners.
Risk Control Recommendations
While rare events may be difficult to prevent, nurse practitioners can glean lessens from the experiences of their colleagues to help enhance their own clinical practices. The following selection of basic risk control recommendations can serve as a starting point for nurse practitioners seeking to evaluate and enhance their patient safety and risk management practices.
Remain current regarding clinical practice, medications, biologics, and equipment utilized for the diagnosis and treatment of acute and chronic illnesses and conditions related to one’s specialty and obtain regular continuing education.
Document all phases of medical treatment, including the care plan, laboratory and diagnostic testing, procedures performed, and medication provided in a timely and objective manner. The substance of all electronic communication related to patient care, including diagnostic test-related communications – whether by telephone, text, email, or instant messaging – should be documented in the patient health care record.
The informed consent discussion represents the first step in managing patient expectations. Discuss (and document) the nature of proposed treatment, alternatives to the treatment, and foreseeable risks and benefits of the treatment options.
Also engage in an informed consent discussion with patients when prescribing medications. Educate the patient about the need for follow-up, and signs and symptoms that should prompt a call to the doctor or a trip to the emergency department.
A self-assessment checklist also is available in the full report to inspire nurse practitioners nationwide to examine their practices carefully.
In Summary
This analysis reveals that, while there have certainly been advances in clinical practice and patient safety, many claims continue to develop. It demonstrates that nurse practitioners are expected to diligently screen, test for, monitor, and/or treat diseases known to have high morbidity and mortality rates and are responsible for obtaining appropriate tests, consultations, and referrals to meet the patient’s medical needs. The report findings also reinforce the responsibility that nurse practitioners must prescribe the right drug, for the right patient, in the right dose, by the right route, at the right times, for the right duration and for the right indications.
Armed with this insight, nurse practitioners can apply key risk control recommendations and resources to focus their efforts on areas of statistically demonstrated error and loss.
Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines, or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.
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