From a nursing perspective, medical recordkeeping is more about risk management than it is about complying with regulations.

“I tell nurses to go back to what they learned in nursing school,” says Debra L. Stinchcomb, MBA, BSN, RN, CASC, senior consultant, Progressive Surgical Solutions of Fayetteville, AR. “No matter if you graduated in 1981 or last year, the rules have not changed. I should be able to take a medical record from any surgery center and do a timeline. That medical record should tell me a story of that patient, the episode of care.”

The record also should reflect answers to these questions: When was the patient admitted? When did the patient go to preop? What orders were implemented in preop? “If a surgery center ever goes to court, then that’s what the plaintiff’s attorney does — set up a timeline,” says Stinchcomb, who serves as chair of the quality committee of the Ambulatory Surgery Center Association. “It’s important to make sure the medical record does that.”

Sometimes, deficits in documentation are related to the physician’s orders. “The physician’s orders should tell nurses what to do, and those orders should be signed, dated, and timed by the physician,” she says. “The nurses need to note those orders, and they should also sign, date, and time.”

When nurses sign and put a date and time on the order, it needs to be a time that is after the surgeon signed and timed it, Stinchcomb stresses. “A lot of times, we see nurses filling in a time for physicians, which they should not do. Or, nurses will note those orders before the physician signs them, and they should not do that.”

That is one area of deficiency, and it is more of a risk issue than a regulatory issue, Stinchcomb offers. “Nurses need to make sure they don’t prepopulate forms,” she cautions. “We see this more often in electronic medical records [EMRs] than on paper, but they shouldn’t prepopulate it at all because you never know what is going to happen with the patient.”

Even if 99.9% of patients experience no issues, there will be that one case that is a problem. “If you prepopulated that chart, then it will be picked up in court, and it will decrease the credibility of the nurse,” Stinchcomb warns.

Lawyers will ask what else the nurse changed in the documentation. They will explain to the jury that the nurse wrote down what happened to the patient before it happened, such as saying the patient was transferred to the PACU with no incident. In reality, the patient experienced a problem, and was transferred to the hospital.

“They shouldn’t go back and change it,” Stinchcomb says. “It’s a double-edged sword. If they make an error, then mark out the error. But once you document, you should not change it.”

Surgery center nurses move fast, and it is easy to forget something. It is acceptable to put in a late entry, per the facility’s policy. The key takeaway is to document correctly. Specifically, any activities that regulations require a physician must be handled by a physician. “The operative report must say everything that was done during the surgery,” Stinchcomb says.

Electronic documentation is faster than paper documentation, and it makes charting efficient. “I would encourage centers to maybe evaluate their paper or electronic record every couple of years to see if there is a way to make it more efficient,” Stinchcomb says. “Whichever process you have in place, try to make it flow better.”

Whether an organization operates one surgery center or 20, review documentation every year or two to see if the process still works and whether any improvements could be made. Another tactic to improve documentation is to offer workshops.

“When I first started working in an ASC, liability insurance carriers would come to surgery centers and do documentation workshops like I do now,” Stinchcomb says. “It never hurts to see if your liability carrier would come out, although they don’t do that as much anymore.”

For surgery center nurses who use EMRs, they should remember to use drop-down menus and click on “N/A” if there is not another answer, Stinchcomb advises. “If a surgery center plans to buy a new EMR, then they should review it carefully and have an ASC nurse look at it,” she says. “You don’t want to buy a practice management product or hospital product. Get an ASC product. As a friend told me: ‘Putting a hospital EMR system in an ASC is like shooting a butterfly with a cannonball.’”

Surgery centers also should audit charts as part of their program. “Sometimes, we do chart audits where they’re just looking for completed signatures, and that’s not very robust,” Stinchcomb says. “Certainly, you need to have those things done, but you should be looking in greater depth.”

For instance, check whether the physician signed every necessary item in the order. “Look at the medical record, and see which items in the medical record they want to look at on a monthly basis to see whether they can follow that episode of care and pick out any issues,” Stinchcomb says. “Develop a medical record audit form, if you don’t already have one, and go through the chart to see if you take issue with anything. Then, take steps to correct it.”