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Victorian Coroner finds resident’s progress notes to be ‘suboptimal’

By Julie McStay21 Mar 2016

Coroner’s findings

The Coroner’s examples of poor documentation included:

  • entries not in chronological order
  • retrospective entries not identified as retrospective
  • no entries for significant periods of time
  • crossed out entries without an explanation

Background facts for Coronial Inquiry into the death of Mr Leslie Alexander

  • The resident had a history of falls and suffered a fall late at night on 30 March 2015, at approximately 12.30am.
  • Nursing notes at 12.45am stated ‘GP and next of kin to be notified by staff in am (sic) due to lateness of incident’.
  • The attending GP’s notes were entered at 3.45pm however it is most likely the GP attended at 3.45am.
  • A further entry was made at 5am by the registered nurse (RN) indicating staff attendance on the resident.
  • The next entry was not made until 11.40am by a physiotherapist stating The resident was drowsy, confused, disorientated and was unable to follow verbal commands.
  • The RN made notes at 12pm relating to the morning’s events. This entry stated The resident had complained of chest pain to his family at approximately 10.30am and staff attended to him.
  • The RN’s notes then included:
    • an ambulance was called;
    • a small bruise was starting to appear at the right eye area; 
    • the resident vomited, after which he was ‘slightly better’ and able to follow verbal commands but still appeared drowsy.
  • An entry was made in the notes after the 11.40am physiotherapist’s entry stating he ‘was slightly confused and very drowsy’.  However this entry was crossed out and directly after the crossed out entry the RN’s 12pm entry stated ‘resident had a good breakfast, all his medication and shower with no issue’.
  • The resident was taken to Maroondah Hospital where a haematoma at the base of his skull and bruising were found and he passed away at 9.20am on 1 April 2015.
  • The Coroner found that once Mr Alexander’s decline was apparent, action was appropriate and no conclusion was made whether earlier medical intervention would have led to a different outcome.

Chronological order and retrospective entries

It is imperative that resident’s progress notes are made in chronological order and documentation should be made at the time an event occurs where reasonably possible.  In the event that notes are entered in a ‘retrospective’ manner the notes should reflect this by stating ‘written in retrospect ’or a similar acknowledgement. And retrospective entries must be recorded under the correct date ie a retrospective entry is made under the date it is entered on, it is not entered under the date it is in relevance to.

There is some commentary in relation to timeframes of retrospective entries and what is considered reasonable. There are no strict guidelines on this and it is case by case dependent, however an entry made weeks after an event is likely to have less relevance. 

No entries for significant periods of time

When providers ‘chart by exception’ (ie where entries are only made if there is a deviation from the resident’s baseline measures) it is of course not unusual for resident progress to have sometimes large periods of time where there are no entries in the notes.  On this occasion however the Coroner specifically criticized a period of some 6 hours overnight where there were no entries. The Coroner’s comments suggest that in this case ie where a resident had been involved in an incident that it was not reasonable to have a period of some 6 hours where there were no entries in the notes. The Coroner suggested that after an incident of the type suffered by this resident frequent observations would be reasonable and entries should be made at the time of the observations. 

Crossed out entries

The resident’s notes contained a crossed out entry which included information in contrast to the next relevant entry.  No explanation was given.  When an entry in a resident’s notes is crossed out an explanation should be provided for the deleted entry.  For example if an entry is not made in the correct resident’s notes and is subsequently crossed out an explanation could state ‘entry made in wrong resident’s notes, details re-entered in correct resident’s notes’.

Documentation in your facility

The findings are a timely reminder that aged care facilities should have clear policies and procedures in place relating to documentation.   And ongoing regular training should be provided to staff to implement the systems and processes provided in the policies and procedures.  If you require assistance with reviewing your documentation policies or would like further information on documentation requirements in aged care please contact Julie McStay, Director - Aged Care and Retirement Living, Hynes Legal.

This content is not intended to be a substitute for legal advice. 

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