Don’t let paths slow down your ideal charting system

By Patrice Spath, ART

Consultant in Health Care Quality and Resource Management

Forest Grove, OR

To gain caregiver acceptance of clinical paths, many hospitals and other health care providers are using clinical paths to document patient care activities instead of more traditional charts. Record documentation by physicians, nurses, technicians, and other clinicians is being replaced by "exception charting."

In the exception-charting methodology, the caregiver verifies completion of each intervention by placing a check-mark or their initials next to the activity listed on the plan of care as the intervention is completed. When an activity is not completed, the caregiver must document the reason patient care did not conform to the predetermined path. Those facilities using the path for documentation purposes retain it as a permanent part of the patient’s record. Using the clinical path as a documentation tool has many advantages:

• Duplicative, fragmented documentation is reduced.

• Time is saved.

• Caregivers’ endorsement of the path is enhanced.

• Caregivers’ awareness of path recommendations at the point of care delivery is reinforced.

• Caregiver collaboration — a characteristic required by the Joint Commission’s standards — is demonstrated.

Drawbacks exist, however. Organizations should carefully consider the following issues when considering using the path as a patient charting tool:

Not all patients are on a path. Therefore, physicians, nurses, and other caregivers will have to deal with two potentially different documentation systems. The dilemma is whether to have two separate documentation methods, or one method that allows integration of all types of patients. An integrated system consists of specific paths for various diagnoses and procedures, and blank or "generic" paths for patient populations for whom pathways have not been developed or who have fallen off their path.

The path must be physically located in a place easily accessible to physicians, nurses and other caregivers. What may be a handy location for one professional may not be the best place for another. Some hospitals have overcome this dilemma by keeping the clinical path at the patient’s bedside. This may prove to be useful for several reasons:

— Nursing staff can refer to the path throughout their shift, update the patient’s progress, and document any variances.

— The path is available for physician rounds.

— The path is available for case manager rounds.

— The path is accessible to all other disciplines who see the patient at the bedside (dietitian, speech pathologist, and others).

One disadvantage of placing the pathway at the bedside is that it is not available when the patient travels off the unit for therapies or diagnostic studies (physical therapy or radiology) unless the bedside chart is routinely sent with the patient. Keeping the pathway within the main body of the chart during the patient’s stay ensures the pathway goes along when the patient leaves the unit and is available for use by all disciplines. This may limit access, however, especially for nurses who make use of the time the patient is off the unit to catch up on paperwork.

"Charting by exception" is more than a record documentation technique. It is a significant change in the philosophy of charting, especially for caregivers accustomed to traditional narrative notes. Expect the transition to exception-based charting to be slow. Many organizations report a phase-in period of one to two years. A significant amount of time is spent educating staff and performing validation studies to ensure that the charting process is executed properly.

Another drawback to "charting by exception" is that it may be discouraged by external reviewers, including health plans and your state health department. Some types of charting by exception fail to sufficiently delineate the patient care activities that were provided by caregivers. Check with the director of your Health Information Management Department to determine if this is a problem in your locale.

The path form itself can become overwhelming once nurses’ and other caregivers’ specific documentation requirements are added. Having all patient care documentation on one form may seem to improve team collaboration. However, if the form is complicated, it may be difficult for caregivers to see the forest for the trees.

Complexity can invite legal trouble

Complex patient record forms can create liability concerns. When the path form is too burdensome for caregivers or so complex that they can’t see blanks needing to be filled in, charting can become incomplete or inconsistent. Missing or disorganized documentation in a patient chart is a red flag for plaintiff’s lawyers who may suggest that gaps in documentation signify gaps and omissions in care.

Patient care goals not met or interventions not performed according to the time frame recommended by the path must be documented. Caregivers already acquainted with exception-based documentation can transition easily to "variance-based" charting. Other clinicians may find it takes them a while to learn to chart only an objective description of the circumstances surrounding the event, not subjective remarks or accusations. (In the chart above is an example of objective variance charting that could appear in a patient’s record.)

Many hospitals that use clinical paths already have developed them into documentation tools or hope to in the future. However, other organizations have realized that documentation efficiencies and team communication are important goals for all patients, not just patients who are on a clinical path. In those hospitals, patient care charting is an organizationwide quality improvement initiative. Once the ideal documentation methodology and the accompanying forms are developed by an interdisciplinary quality improvement team, they determine whether clinical path recommendations can be integrated with their record charting strategy. More and more groups are realizing that clinical paths shouldn’t be the major consideration when designing a record documentation process. The goal of information management for all patients must be the motivating factor.