Title

The Role of Documentation Quality In Anesthesia-Related Closed Claims: A Descriptive Qualitative Study

Document Type

Article

Publication Date

9-1-2016

School

Professional Nursing Practice

Abstract

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.

Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Clinical documentation is the process of generating a narrative of patient care for the purpose of informing clinical decision support tools. It thus serves as the legal record, assists in providing documentation for purposes of reimbursement of the services provided, and also creates a repository of information for data analysis (eg, clinical research or quality improvement initiatives). Poor documentation, on the other hand, provides inadequate information, which can ultimately affect patient safety. Moreover, it can increase malpractice risk exposure utilizing inferior quality information to guide patient care decisions. Sound documentation can improve the quality of patient care and help to support a defense to the quality of care provided in the event that a healthcare professional liability claim arises. In addition, exploring the antecedents, causes, and consequences of poor documentation can be designed to improve documentation practices. For purposes of this study, poor documentation, as used in this manuscript, is a broad term that can refer to a negative presence of one, or more, of the attributes that define documentation quality.

In the 1980s, anesthesia-related closed claims studies arose from the need to improve patient safety and outcomes while simultaneous addressing the issue of rising malpractice insurance costs. Although retrospective data are not suitable for proving causation, closed claims databases represent useful tools to identify potential precipitating factors that may lead to increased legal liability. When potential sources of increased legal liability are identified, targeted interventions that seek to improve patient outcomes and decrease malpractice risks can be generated. The findings derived from this examination will be used to develop recommendations to improve documentation practices and support patient safety initiatives.

Publication Title

CIN: Computers, Informatics, Nursing

Volume

34

Issue

9

First Page

406

Last Page

412

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