Clinical Documentation – The Answer to the Story

Clinical documentation is the final fact in any story being told. Clinical documentation can and will make or break a case and unfortunately for most facilities, it’s frequently very bad. Discovering poor clinical documentation, failures to record care or intentional alteration of records requires more than just reading the nurse notes.


Clinical documentation is no longer just the facility’s records of nursing and physician summaries.  In today’s world of medical providers it also includes every single document regarding care as in  the EMS and/or Fire Rescue record, Air Flight records, 911 call logs and transcripts, outside provider records, faxes and emails between providers, text and phone records, voice orders, PT and OT notes,  and much more.  These records then taken together as a whole, can tell the true story with consistency and substantiation.


Clinical documentation is a legal document that should clearly and precisely tell the account of a patient’s medical encounter with all the involved caregivers.  It should provide a complete and accurate account of all provided care. Unfortunately, a substantial amount of documentation that we review on a regular basis is just as bad today as it was 20 years ago.

Looking For Red Flags


As legal nurse consultants one of the primary jobs is looking for red flags in the provided documentation.  Attorneys know that red flags can either make or break a case and as legal nurses our job is to uncover those red flags and educate our attorney clients. Some of the potential red flags include:

  • Lack of claimed or ordered treatment.
  • Delayed, substandard, or inappropriate treatment.
  • Failure to accurately assess and monitor the patient.
  • Failure to notify a provider of problems or a change in condition.
  • Late entries that aren’t documented as such or that appear to be self-serving rather than genuine addendums.
  • Charting inconsistencies such as lapses in time.
  • Discrepancy between physician/nurse notes and CNA or other caregiver charting.
  • Fraudulent or improper alterations of the record.
  • Pre-filled in charting such as charting several days’ worth of medication administration in advance.
  • Destruction of records or missing records.
  • Pictures and/or descriptions of injuries that do not match the claimed mechanism of injury.
  • Battles between health care providers.
  • References to an incident report.
  • Bias against the patient
  • Patient abandonment.
  • Lack of patient teaching or discharge instructions.
  • Lack of informed consent.

Examples of Red Flags – Information not in provider notes


Turn every two hours


In the case of a pressure ulcer, the physician order states “Turn every two hours.”  The nurse notes make no mention of turning, but in deposition the nurse claims the care was given by the CNA.  How do we prove or disprove the claim of care given?


The CNA flowsheets hold a wealth of information that must be collected by the facility as these flowsheets are the basis for all CMS and State DHS billing. When reviewing these sheets, we can then see if the care was documented.  If this care was not documented, but the facility claims on the MDS (Minimum Data Set) that it was done; CMS and the state will likely take grave exception to this inconsistency and can help the attorney with their case.


The Fall – Using outside records to discover the story


The nurse states in a note that she saw the patient stand up from a wheelchair and fall even though the patient had been warned not to try to walk without calling for a nurse. In addition the nurse stated the chair alarm went off. Thankfully, the EMS records were requested; which are wholly separate from the facility record.  Fortunately, the story told to the EMS providers and charted in the EMS records can provide another story. For example in this scenario, the story told by medication aide or nurse to the EMS providers was that she came in to give meds and found the patient on the floor next to the bed. Later in deposition, the staff disclosed there was no alarm. Billing records support this as there is no alarm billed.


In the case above, the facility had been fined the year before for the same exact issue by State inspectors.


The injury doesn’t match the story


A patient dies after a fall which resulted in a significant head injury, a broken neck,  and a broken arm.  The patient is completely immobile and requires total assistance for any activity. The nurse records that she was “pushing the patient very slowly” in the wheelchair when the patient suddenly flew forward approximately 2 feet hitting the door jamb of the bathroom with her head; then bounced backwards another foot, striking the wall with the back of her head and falling to the floor. The nurse documents, she believes the patient jumped out of the chair by herself.


In the above case, carefully documenting the prior condition of the patient becomes critical in order to show the patient could not have “jumped” out of anything.  Previous staff notes document a total assist patient; physical therapy notes indicate little to no leg movement, and occupational therapy notes indicate little to no interaction. Lastly, the physician notes all paint the picture of an immobile patient who was reasonably unable to jump.



Just the Facts

Clinical documentation isn’t just the nurse or physician notes, but rather an entire collection of documentation from many different sources.  By reading all the available documentation, the true story can be compiled from all the facts found within the record.  Facts are extremely difficult to refute and a well-researched case is much easier to prove or disprove the claimed damages and injuries.