Q&A: Lack of nursing documentation for clinical indicators

Q: I’m running into a big problem with the nursing documentation. The nursing notes have inconsistent documentation of lung assessment, missing documentation when it comes to the patient being on room air or oxygen (O2), and the intakes and outputs (I&O) are completely missing. Is this an area I should get involved in, or turn it over to the nurse educator, the quality department, or the nurse manager? I am not finding the clinical criteria to meet a number of diagnosis and the nursing documentation (or lack of) is troubling.

A: I see this as not only a documentation issue but a patient safety issue. Coders and CDI specialists view the record as a tool to capture accurate reimbursement and severity of illness. The most important function of the record, however, is to allow for communication amongst caregivers to promote development of a safe and appropriate plan of care. If this is not happening, then how do we ensure the patients receive the specific care they need?

CDI specialists may among the few who read the entire record. Because of that we are much more aware of any documentation inadequacies by any caretakers including our providers, nursing, and ancillary staff. When I’m teaching, I always say that CDI specialists need to educate everyone who documents in the record.

For example, CDI specialists depend on nursing assessments to record the patient’s height and weight to electronically compute body mass indexes (BMIs). When I was working in a facility, we found the patient weights very unreliable—often changing drastically from day to day. This obviously created an issue for code assignment, but also created an issue for providers who depend on accurate weights when managing certain conditions related to fluid levels such as heart failure and renal function. We took this concern to the chief nursing officer and nursing management. During the discussion, we discovered the nursing staff had not been properly oriented in the use of the new bed scales, thus their inconsistent practices led to wildly inconsistent weights. The education was rolled out and the documentation stabilized.

This experience led to more discussions with nursing. We brought education to their staff meetings, orientation, and other arenas. We spoke to how important their documentation and assessments were in assisting us with our goals in CDI. They began to understand how important their mental status assessments, skin/wound assessments, activity assessments were.

When we praised them for documentation that allowed us to query for a more specific diagnosis or allowed us to query for a missing diagnosis their response almost consistently was, “I didn’t think anyone read my notes.”

If one doesn’t think it matters, why would they invest much time in providing quality documentation? Empower them and other ancillary professionals by letting them know how valuable their documentation is to our efforts. This education must also include a description of what CDI is and why you are reviewing records.

I suggest you first speak to your manager or supervisor and develop a plan of action. I can share with you from my own experience this can influence change.

I would also suggest that, if you are using an electronic record and you find specific information is missing or difficult to understand, work with nursing and IT to allow for better capture. This effort will create an “army” to assist you in your efforts and we need all the help we can get.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI education specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.