“WNL.” What gets asked about a checkbox assessment, and what to chart instead

On the stand · 11 of 12

WNL.

Within normal limits of what, and when did you look? WNL says a finding matched your unit's definition. It does not show the value, what changed, or what is normal for this patient.

What they ask about it

A nurses' liability insurer (NSO), on how a plaintiff's attorney reads thin exception charting
Does this document tell the full story of the patient’s condition and of our professional assessment and care?
Nurses’ notes with few explanations, little description of key findings, or no mention of periodic patient checks could be construed as negligence by a plaintiff’s attorney guided by the premise, not charted, not done.
Source: NSO: Charting by exception: the legal risks
A legal nurse consultant at Med League, a firm that supplies expert witnesses to trial lawyers
And what if a “normal” finding in the definitions is abnormal for the patient?
And what if a “normal” finding in the definitions is abnormal for the patient? Will improvements be missed in a patient who is normally short of breath and is no longer short of breath? ... Nursing defendants may explain missing documentation by stating they chart by exception.
Source: Med League: Charting By Exception: A Trap for Poor Documentation

It happened in court

Lama v. Borras, 16 F.3d 473

U.S. Court of Appeals for the First Circuit · 1994

After back surgery a nurse noted a “very bloody” bandage, and later pain at the incision, but the hospital had told nurses to chart by exception, so there were no notes for every shift. The jury could find that the gaps delayed the diagnosis of the infection, and the appeals court let the verdict stand.

one former nurse at the Hospital who attended to Romero in 1986 testified that, under the charting by exception policy, she would not report a patient’s pain if she either did not administer any medicine or simply gave the patient an aspirin-type medication (as opposed to a narcotic). ... the jury could have reasonably inferred that intermittent charting failed to provide the sort of continuous danger signals that would be the most likely spur to early intervention by a physician.

Beechwood Restorative Care Center v. Leeds, 856 F. Supp. 2d 580

U.S. District Court, Western District of New York · 2012

Two plaintiffs tied to a nursing home in Rochester sued New York State Department of Health employees, claiming retaliation that ended with the home's closure. The court quoted a final report by state investigators (MFCU): at the hearing, the home's charting by exception was the core issue, and the thin record made the care look poor until testimony and interviews said otherwise.

The core issue the ALJ continually referred to was Beechwood’s policy of charting by exception [a record-keeping procedure]. Due to the lack of documentation, it appeared that poor care was given. However, testimony during the hearing and interviews conducted by our office refuted that contention.

Write instead

1400: Lower abdominal dressing intact with 3 × 2 cm area of serosanguineous drainage, unchanged from 1200. Incision not visualized beneath dressing.

Observations call for specific detail: Record the color, consistency and quantity of wound drainage—“about the size of a quarter,” for example— rather than noting only that the dressing was “very bloody.”

Source: NSO: Charting by exception: the legal risks

What WNL leaves out, with five before and after rewrites

Already charted it this way?

Do not change the original entry. Not for any reason, and not after you hear there is a claim.
Never alter a patient’s record - that is a criminal offense
Source: NSO: Do's and Don'ts of Documentation
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Source: NSO, Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability
Add a late entry, the way your policy says. Mark it as late. Write only what you actually remember.
If something needs to be added to documentation, always chart that information with a notation that it is a late entry and include the time and date
Source: NSO: Do's and Don'ts of Documentation
Use the time you are writing it. Name the time of the event inside the entry; the entry itself carries today's time.
Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
Source: ACDIS Q&A: Policies for late entry documentation
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Source: The Health Law Firm, 25 Legal Dos and Don'ts of Nursing Documentation
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
Source: CNA and NSO: Nurse Spotlight, Preparing for a Deposition
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
Source: The Health Law Firm: Preparing for a deposition, for nurses
At the deposition, do not guess. Answer what you saw and what you know. Not remembering is an answer.
7. If you do not know the answer to a question, do not guess. Say that you do not know the answer. 8. If you do not remember something, say so.
Source: CNA and NSO: Nurse Spotlight, Preparing for a Deposition
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Source: I Advance Senior Care, Nursing depositions: Duty or disaster?

Not legal advice. Your facility policy, your state and your own attorney are what bind you. Every question and every quote here links to where it was published; read the source, not us. Written by a med-surg RN, ten years, day shift. Why there is no name on it.