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Regulations Update

Federal Regulation - F514 Clinical Records

Marci Pederson, RN, BSN, Nurse Educator/Consultant

F514 titled Clinical Records was the 6th most cited regulation as a deficiency during 2009 in long term care facilities in South Dakota. There were 24 deficiencies written for F514.

This regulation says, “(1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are: (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. (2) The clinical record must contain: (i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The plan of care and services provided; (iv) The results of any preadmission screening conducted by the State; and (v) Progress notes. Some of us might be thinking its just paperwork. It cannot possibly be the same as the actual quality care our facility provides to our residents. Are clinical records really just paperwork? I would like to share a small reflection I wrote last year and then expand on it in relation to clinical records. You might think this is a stretch but stay with me on this.

Journal Entry - 5/29/09 - The Wisdom of Beans

My husband came into the house this morning very excited saying, "Come out and see the second row of beans!" We had been patiently waiting for the Roma beans (his favorite green beans) to break through the soil. We went out to the garden and sure enough the second row was coming up! Then I looked at the bean plants pushing through the soil and realized that when one bean plant comes through the crack it has made in the soil, that bean makes it easier for the bean plants on both sides of it. And then in a ripple type of effect, more beans come up until the whole row is standing proudly in the sun.

It is this way in life. I remember and feel gratitude to those who went through a difficult time before me who could reach out to me and say to me, "You will come through this".

I think about those special persons who made that first opening in the soil and then shared so the rest of us are able to come through the hard crust too and share in making something beautiful to benefit others. The beans stand tall together; their story illustrates the wisdom found in a simple row of beans. I now see green beans in a whole new light!

When we all work together, the clinical records of our residents/patients tell us their story. It is through their story that we as health care workers are able to provide quality care because we are then able to know them physically, mentally, emotionally, and spiritually. Their stories are in writing so all of the team can access their information and care for them. In order to do this, everything must be included. We usually learn from our errors so I will share some examples of clinical records missing different characteristics required in the regulation.

Professional Standards and Practices

When we write a story about a topic there are certain expectations or standards regarding that topic. In the little story about the green beans, we can expect the beans are grown in soil. With clinical records, there are professional expectations or standards and practices on which the records are based. If you have questions about professional standards you can review my update on F281 Professional Standards.

One of our professional standards and practices with clinical records is keeping them confidential from the public. Another is when there is a physician order, the order will be transcribed so that the physician’s direction for care is completed unless there is a need for clarification. For example, if the order is for a sulfa medication for a urinary tract infection and the resident/patient is allergic to sulfa drugs, the transcribing nurse needs to get this order clarified with the prescribing physician. How does the nurse know the resident/patient is allergic to sulfa drugs? This information is included in the resident/patient’s clinical record.

Completeness of Clinical Records

The story needs to be complete in order for the health care team to plan their care. The little story about the beans was complete in its little message about beans and how they are similar to people who help others.

I came across this example a few weeks ago. Review of a clinical record revealed the record contained no history and physical. The resident/patient had been admitted six days prior to the review, and the facility’s policy required a history and physical in the clinical record completed either within 30 days prior to admission or within 72 hours after admission. The history and physical lays the ground work to plan the resident/patient’s medical care. For that reason, the history and physical information needs to be available and in the clinical record at the time of admission or within the time frame set by the facility.

Accuracy of Clinical Records

The story needs to be accurate for the resident/patient. The story about the beans would not have made sense if in looking at the garden we discovered the beans had mutated and were producing cucumbers.

If the story or clinical records contain information meant for another person, the resident/patient will very likely receive inappropriate care. An example to help understand the priority of accurate information occurred a few weeks ago. A resident had sustained a fractured hip and needed to be transferred to the hospital for treatment. Prior to going to the hospital the resident’s care plan included interventions to encourage her to drink at least two quarts of liquids per day due to problems with dehydration. When she returned from the hospital her lab reports reflected early kidney failure. New orders for fluid restriction were written for no more than one and one half quarts per day for intake. The care plan was updated to include the information about the fluid restriction but the intervention for encouraging fluids was not deleted and so there was confusion about what the resident needed. She received fluids at mealtime and she was also provided with a full water pitcher between meals. With accurate information on the care plan, the staff is able to provide the care that is needed for the resident/patient without confusion.

Readily Accessible Clinical Records

The story needs to be accessible. When a story has a helpful message, it does not provide help unless it is shared and is accessible. When I wrote about the wisdom of the beans, I decided I needed to share this story with my husband, daughters, and close friends so this message could be accessible to them.

Most facilities have certain processes when it comes to clinical records. There is more than one way to make clinical records accessible. Why is it necessary to have clinical records accessible? Who needs to know what is in the clinical records? Health care team members need to have access to the clinical records in order to provide care to the resident/patient according to the resident/patient’s plan of care.

Here is an example of a glitch in accessibility. A facility was gradually changing over from paper clinical records to electronic clinical records for all of the nurses’ documentation. All of the nursing staff had access to the resident/patients’ electronic records except for temp nurses. The electronic nurses’ notes still needed to be printed so everyone who needed to use the clinical record would have access to it. In addition to the temp nurses, the pharmacist consultant did not have access to the electronic nurses’ records. The plan was to print off the nurses’ notes on a monthly basis; this would save paper because the information on one page could include more than one day’s nurses’ notes. If they printed the notes every day there would be more paper used because only one day’s documentation per page would occur. The intent to save paper was good, but the resident’s care had gaps because the temp nurses did not have all of the information they needed on a daily basis, and the pharmacist consultant did not have the information needed to conduct a valid monthly drug regimen review. The lack of accessibility of the clinical record for the pharmacist consultant resulted in a hypnotic being administered for a longer period than was recommended for an elderly individual who then sustained a fall as a result of the side effects of the hypnotic medication.

Systematically Organized Clinical Records

The story needs to be systematically organized. We usually expect a story to have a beginning, middle, and an end. Clinical records need to be systematically organized as well, and because there is so much more information involved in a clinical record it can be quite complicated.

Have you ever looked for something in a clinical record that you needed to know but could not find it because it was accidentally filed in the resident’s spouse’s clinical record or was placed in the wrong section of the clinical record? When this happens the resident/patient may not receive the care they need. Let’s take time to thank the person assigned to filing information into the clinical records. This is an important job, and it makes a big difference in the resident/patient’s care when the job is completed consistently and accurately.

Does your facility need help with complying with the clinical records regulation? Do the math. What does it cost when non-compliance is an issue? Call 605-668-8475 today for a consultation with our survey specialist. Avoid surprises – Know what is wrong before the survey!


 

 

Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.

Have a question for Marci? A topic idea for her next column? Need more information on having a mock survey at your facility? Send her an email at mapederson@avera.org.