Records and Reports: Accurate Documentation to Limit Liability and Improve Patient Care Protection Status

By Glenda Motta RN, MPH

Recently, I attended the WOCN Mid-Atlantic Regional conference. There, a nurse attorney discussed strategies to limit liability and improve patient care. The Maryland Patient Safety Law requires that hospitals report all Level I events to the state Office of Health Care Quality (OHCQ). The penalties for failing to meet these requirements can include revocation of the hospital’s license or a fine of $500 per day.

All AVOIDABLE Stage III/IV Hospital Acquired Pressure Ulcers are Level I reportable events. In addition, any pressure ulcer present on admission that progresses to a Stage III/IV during hospitalization must be reported if the progression was avoidable.

She stressed that small numbers are reported, and the vast majority come from two large hospital systems. The OHCQ believes that hospital acquired pressure ulcers are still largely under reported in Maryland. The state links hospital payment to performance based on a set of Hospital Acquired Conditions. Hospitals lose money if they have a higher rate of preventable conditions than expected.

She concluded that failure to identify a pressure ulcer at the time of admission create the potential for:

  • A state reportable event
  • A reduced hospital reimbursement rate
  • A medical malpractice lawsuit

Even more interesting is the 2012 work-plan for the HHS Office of the Inspector General which states: “We will review the type of information that hospitals’ internal incident reporting systems capture about adverse events and determine the extent to which hospital systems captured adverse events and reported the information to external patient safety oversight entities. Most hospitals have incident reporting systems that enable medical and hospital staff members to report information about patient safety incidents when they occur and to use reported information to prevent recurrence, hold staff members accountable, and notify families. We will use data to examine the national incidence of adverse events among hospitalized Medicare beneficiaries.” (

It never hurts to reiterate the attorney speaker’s key points:

  • Missing, incomplete, or illegible documentation can seriously impede patient care and the defense of a malpractice claim, even when the care was appropriate
  • If the Medical Record is inconsistent, the Medical Record is NOT reliable
  • Consistency in identification and staging of pressure ulcer by nurses, physicians, and wound care clinicians is critical
  • Description should be consistent: pressure ulcer v. deep tissue injury; pressure ulcer v. incontinence associated dermatitis; staging v. unstageable
  • Advise the bedside nurse that it is better to DESCRIBE than to stage with no description
  • Make the Electronic Medical Record work for you: establish “alerts” for nurses, including a significant change in Braden Score or significant change in a pressure ulcer
  • Alerts for the WOCN: High risk Braden Score, presence of pressure ulcer on admission, identification of new pressure ulcer during hospitalization, etc.
  • Alerts for the physician– “A New Pressure Ulcer has been documented, do you have any orders?”

This leads me to the following questions for thought:

Does your state have such a law that requires reporting pressure ulcers?
Is your documentation accurate and consistent?
What steps do you take in clinical practice to limit liability and ensure reporting accuracy?

I would love to hear about your thoughts and experiences in the comments section.

About The Author
Glenda Motta RN, MPH is a reimbursement consultant and wound care expert, publishing over 125 articles and books, serving as the President of the WOCN (1987-1989), and founding GM Associates, Inc., a healthcare marketing and reimbursement firm.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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