Improving Medical Documentation Through Education

The aim of this DNP project was to develop an educational module about documentation for nurse midwives and nurse midwifery students. Formal education on documentation has been shown to improve charting practices for resident physicians when compared to those who received no training. Improved charting practices can reduce the risk of medical malpractice, which is common among obstetric providers. A recent survey of members of the American College of Nurse Midwives (ACNM) found that over 30% had been named as a defendant in at least one case. There is currently no specific formal training for student nurse midwives regarding their charting practices. Scenario-based learning modules have demonstrated effectiveness with individuals who have existing knowledge of a subject, and can be used for medical documentation education. Litigation among nurse midwives is increasing in the United States. Incidence of legal action increases commensurately with the number of births attended by practitioners. Incomplete or missing documentation of a case puts a provider at risk for being found negligent. The objectives of this project were to create a scenario-based educational module for nurse midwives and students with the intent of increasing their knowledge of defensive and effective documentation, pilot the module among practicing midwives and students, gain feedback from participants through a pre and post test module assessment, and disseminate the module to ACNM locally and nationally. The module was created using the Camtasia® program. Information was presented in a slide show video format with voice over narration. Module content was included based on data from literature review and content expert recommendation. The module was viewed by nurse midwives and students, who also completed a pre and post module assessment. Results indicate an improvement (p < .001) in participant scores by 28% after viewing the module. Feedback on the content and format of the module was elicited from participants with a free text question on the post module assessment. A revised module was then submitted to the ACNM for consideration for inclusion on the organization's website. A poster presentation of the project was presented to the local ACNM affiliate members. The module will be utilized in the nurse midwifery and women's health nurse practitioner graduate education programs at the University of Utah. Documentation is an important element of medical training and practice, and is the best defense for a provider in a medical malpractice case. This module provides basic elements of documentation training and could be expanded to provide more extensive training for nurse practitioner students as well as professional midwives. This module could also be used in its current state as an additional resource for educators teaching defensive medical documentation to reduce medical litigation.

Provider Documentation 1 Improving Medical Documentation through Education Carlie Kay Naval, BSN, RN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice Executive Summary Provider Documentation 2 The aim of this DNP project was to develop an educational module about documentation for nurse midwives and nurse midwifery students. Formal education on documentation has been shown to improve charting practices for resident physicians when compared to those who received no training. Improved charting practices can reduce the risk of medical malpractice, which is common among obstetric providers. A recent survey of members of the American College of Nurse Midwives (ACNM) found that over 30% had been named as a defendant in at least one case. There is currently no specific formal training for student nurse midwives regarding their charting practices. Scenario-based learning modules have demonstrated effectiveness with individuals who have existing knowledge of a subject, and can be used for medical documentation education. Litigation among nurse midwives is increasing in the United States. Incidence of legal action increases commensurately with the number of births attended by practitioners. Incomplete or missing documentation of a case puts a provider at risk for being found negligent. The objectives of this project were to create a scenario-based educational module for nurse midwives and students with the intent of increasing their knowledge of defensive and effective documentation, pilot the module among practicing midwives and students, gain feedback from participants through a pre and post test module assessment, and disseminate the module to ACNM locally and nationally. The module was created using the Camtasia® program. Information was presented in a slide show video format with voice over narration. Module content was included based on data from literature review and content expert recommendation. The module was viewed by nurse midwives and students, who also completed a pre and post module assessment. Results indicate an improvement (p < .001) in participant scores by 28% after viewing the module. Feedback on the content and format of the module was elicited from participants with a free text question on the post module assessment. A revised module was then submitted to the ACNM for consideration for inclusion on the organization's website. A poster presentation of the project was presented to the local ACNM affiliate members. The module will be utilized in the nurse midwifery and women's health nurse practitioner graduate education programs at the University of Utah. Documentation is an important element of medical training and practice, and is the best defense for a provider in a medical malpractice case. This module provides basic elements of documentation training and could be expanded to provide more extensive training for nurse practitioner students as well as professional midwives. This module could also be used in its current state as an additional resource for educators teaching defensive medical documentation to reduce medical litigation. Committee: Chair: Pamela Phares, PhD, APRN, CNM; Nurse Midwifery Specialty Track Director: Gwen Latendresse, PhD, CNM; Assistant Dean for MS and DNP programs: Pamela Hardin, PhD, RN Content Experts: Angela Deneris, PhD, CNM, expert legal witness; Andrew Black, PhD, M.B.A. Educational Specialist Provider Documentation 3 Table of Contents Page Executive summary 2 Problem statement 4 Clinical significance 4 Objectives 6 Literature review 6 Theoretical framework 10 Implementation 11 Evaluation 13 Results 14 Recommendation 15 DNP essentials 16 Conclusion 16 References 18 Appendices A. Institutional Review Board member response 20 B. Doctor of Nursing Practice Project Proposal PowerPoint 21 C. Pre and post module questionnaire 27 D. Data and analysis of questions 30 E. Abstract Application for ACNM regional Affiliate meeting 35 F. Poster presentation 36 Acknowledgements and Special Thanks Pamela Phares, PhD; Angela Deneris, PhD, Andrew Black, PhD, Andrew Wilson, PhD Problem Statement Provider Documentation 4 Litigation is a common concern for many obstetric providers (ACOG, 2012). In the last several years litigation, specifically among midwifery providers, has become a growing concern. In a 2009 survey of members of ACNM researchers found that 32% of respondents had been named in a lawsuit at least once in their careers. According to this study, the likelihood of being involved in a lawsuit was most closely correlated with exposure to births over time (Guidera, McCool, Hanlon, Schuiling & Smith, 2012). For providers involved in lawsuits, evidence suggests that the most likely reason for losing is poor documentation. Complete and thorough documentation of care is arguably the most important supporting evidence providers have to defend their medical practice (Samadany, 2012). There are multiple challenges and few resources regarding important components of medical documentation in the event of an emergency. This is especially true with the widespread use of electronic health records (EHR) (Samadany, 2012). Addressing these challenges through a teaching module for obstetric providers on the American College of Nurse Midwifery website will help improve knowledge gaps that may exist and improve charting accuracy and completeness. Clinical Significance There are multiple risks associated with incomplete, vague, or missing documentation after an adverse event occurs. These risks include: litigation, revocation of professional licenses, loss of employment, financial loss, personal stress, and psychological distress, among others (ACOG, 2012). It is very important that all providers enter their advanced practice with a thorough working knowledge of correct Provider Documentation 5 documentation for all procedures. This is particularly important for novice practitioners, as well as seasoned providers. Evidence indicates that the more births attended, as well as inexperience, can increase the risk for litigation. According to a 2009 study by the ACNM, there was a strong correlation between the number of births attended and an increased likelihood of being involved in litigation (Guidera, McCool, Hanlon, Schuiling & Smith, 2012). Specific knowledge of defensive documentation during adverse events and knowledge of which birth outcomes are most frequently associated with litigation allows providers to protect themselves in the event of an unforeseen poor obstetric outcome. Knowledge will also give providers confidence when documenting in EHRs, which can make detailed charting difficult with "yes" and "no" standardized templates (Samadany, 2012). Further education in documentation has the potential to improve patient care, increase provider comfort and security, and ultimately protect practitioners from perceived negligence or malfeasance (Isoardi, Spencer, Sinnott, & Eley, 2015). Stakeholders in this project were all nurse midwives who desired to gain knowledge and understanding of defensive and comprehensive charting. This module pertains specifically to charting thoroughly in the event of an adverse outcome. The goal of the project was to publish the module on the ACNM website, so that active members have access to this education as an added benefit to their membership. Purpose The goal of this scholarly project was to enhance nurse midwife knowledge of the importance and necessity of complete and defensive documentation, particularly following an adverse outcome. Objectives Provider Documentation 6 The first objective was to create an educational module for obstetric and gynecological providers to improve their knowledge of key documentation principles of defensive charting to reduce the incidence of legal action against these providers. The second objective was to evaluate the module's content and format by creating a pre- and post-module test that was distributed to study practicing CNMs and midwifery students in that state of Utah. Paired t-tests were used to compare before and after scores to assess learning. Feedback from participants regarding the content and format of the module was elicited with a free text question for recommendations or feedback on the post module questionnaire. The module was submitted to an ACNM representative for consideration for inclusion on the website. The project was also presented to the Utah ACNM affiliate via a poster presentation at a local meeting. Literature Review Literature Search Strategy PubMed, CINAHL, and Medline Plus were searched using terms including: "midwife AND litigation", "medical documentation AND litigation", "midwives AND documentation", "shoulder dystocia documentation AND midwives", "residents AND documentation", "documentation OR litigation OR midwives", "medical students OR documentation OR midwives", "documentation OR midwives OR litigation." Results included in the literature review were peer-reviewed articles from 2011 to 2016. Studies that were older than 2011 or of poor quality data were not included. Other data sources included lecture material provided by content experts. Provider Documentation 7 Medical documentation is a standard of care for all healthcare providers. Documenting care is a provider's way of proving appropriate and timely medical treatment to patients for whom they care. These records are often the sole evidence presented at trial to prove negligence or wrongdoing in medical malpractice litigation. Evidence has shown that the most common reason healthcare providers lose malpractice cases is poor or incomplete documentation of care (Samadany, 2012). Most medical education programs do not have specific courses tailored to teaching complete and defensive documentation. This could potentially put providers at risk in the event of legal action, particularly after adverse outcomes. Clinical documentation is intended to communicate patient condition and treatment to all members of the healthcare team (Kuhn, Basch, Barr & Yackel, 2015). Over time, medical records have evolved and are most commonly associated with EHRs. These systems have changed the process of charting in multiple ways. While EHRs may make some aspects of charting simpler, this mode of charting may also cause confusion and complication. This is particularly true when rigid templates are used and multiple pertinent negatives are included. In his book entitled The Digital Doctor, author Robert Wachter details some of the frustration and difficulty associated with electronic medical records that are prevalent in most healthcare systems today. He states "the combination of all the checkboxes, templates, and copy and paste has led to notes that are so loaded with bilge-much of it questionable utility and some of it questionable veracity, as you'll see-that, while the billers may be overjoyed, the clinicians cannot do their work" (2015, p. 72). Often patient's charts become so loaded with information copied or left from previous visit notes, that it is difficult to decipher what is pertinent. Provider Documentation 8 Researchers argue that defensive medicine has resulted in longer notes that do not necessarily improve patient care or reduce litigation. As a result, researchers recommend, "clinical records should include the patient's story in as much detail as is required to retell the story" (Kuhn et al., p. 303). Researchers also suggest that providers take care not to load notes with erroneous or repetitive data and use caution when using template type charting. Narrative documentation should still be used to communicate medical issues of individual patients. Lack of knowledge of proper format, time constraints, and forgetting key details in the medical record have been identified as common barriers to defensive charting. Leaving out key information is particularly common when charting is not done proximal to the event and a provider then relies on retrospective analysis for details surrounding care. Wood (2011) sums up the importance of good documentation by stating "good record keeping is crucial to the provision of safe and effective care and an integral part of nursing and midwifery: not an optional extra to be fitted in if circumstances allow" (p. 20). Researchers of one study published results from a survey conducted by the ACNM regarding litigation involving certified nurse midwives that were members of the professional organization (Guidera, McCool, Hanlon, Schuiling & Smith, 2012). In the research that was conducted 32% of responding midwives had been named in a lawsuit at least one time in their career. Data from this study revealed that age of the midwife named, geographical region of practice, and number of births attended were all significant risk factors for involvement in litigation. However, researchers also found that Provider Documentation 9 many of the lawsuits brought against these midwives was abandoned or settled before going to court. Researchers in a similar study conducted by the American Congress of Obstetrics and Gynecology in 2015 reported that 73.6% of respondents had a professional liability claim made against them at some point in their career (Guidera, McCool, Hanlon, Schuiling & Smith, 2012). In this study, 49.7% of respondents reported making a major change in their clinical practice due to fear of litigation or insurance availability requirements. These changes included performing more Cesarean sections, no longer offering trial of labor after Cesarean section (TOLAC), or ceasing the practice of obstetrics entirely. In a poll conducted by Adinma (2016), 826 obstetric providers in Australia were asked if they intended to carry on with obstetric practice in the next five years. Of those participants, only 44% planned to practice obstetrics long term. The second most commonly cited reason for leaving obstetrics was fear of litigation and fear of increasingly high indemnity costs. Medical litigation requires four basic elements be present in order to prove negligence on the part of a provider (Adinma, 2016). Those elements include existence of a duty of care to the patient, breach of duty by a provider, and proven damage or injury that can be traced to the alleged breach of care. In order to disprove medical negligence a provider and his or her legal counsel must often rely solely on the medical record documenting the care provided. Without proper paper trails, negligence could be proven or assumed. Provider Documentation 10 With increasing incidence and concern surrounding litigation in the field of obstetrics, it is vital for providers to take an active role in protecting themselves as much as possible. According to Adnima (2016) health professionals should document consent, procedures, and activities with careful consideration of time. In the event of a legal case, these records provide a good legal defense for the provider. Taking proper care to document cases appropriately and defensively is a sound way to decrease the risk of losing a medical malpractice case. Theoretical Framework Meyer, Moreno, and Sweller's e-learning theory consists of cognitive scientific ideas that explain how electronic technology can promote effective learning for adults. The theory breaks down cognitive load into three categories. These categories are germane, intrinsic, and extraneous. Germane load is the effort needed to understand a task and store it in long term memory. Intrinsic load involves the effort that is needed to actually perform a task. Finally, extraneous load is the effort imposed by the way that a task is delivered (2015). The e-learning theory focuses on multimedia principles that reduce extraneous cognitive load, while increasing germane and intrinsic load at user-appropriate levels. The theory states that learners benefit from the combination of audio, visuals, and text. Learners are more likely to learn the material with at least two of these elements, compared to just one. The theory also states that the use of audio narration accompanied by visuals is more effective than visuals with on-screen text (Mayer, Moreno, & Sweller, 2015). Provider Documentation 11 This theory gives helpful guidelines for creating educational material for adult learners. Meyer, Moreno, and Sweller recommend allowing learners to control the pace of the information. Media with a pause, reverse, and forward button allows for more effective learning. They also recommend breaking large concepts into smaller pieces to maximize understanding, and reduce confusion. For voice-over narration, polite and conversational tones have been shown to promote deeper learning (2015). This theoretical framework was chosen because of its relevance to the creation of an educational module for adult learners with varying degrees of prior knowledge about proper documentation. The theory highlights important principles that can be applied to this module to increase learner reception and understanding of the information presented. These e-learning principles can be used to guide the program, format, and graphics in creation of the learning module. Implementation A doctoral project proposal PowerPoint (Appendix B) was presented in October 2016. The project outline was approved for implementation at that time. An educational module was created by working with Ann Deneris, PhD, CNM who is an expert legal witness in medical malpractice cases for midwives. I also received feedback and guidance from Andrew Black, PhD, MBA, RN, who is an educational technologies expert with an extensive IT background and expertise in nursing informatics. Mamie Guidera, MSN, CNM who is the ACNM professional liabilities representative was also contacted for feedback on content to be considered for inclusion in the module. The project was built upon existing educational resources provided by Dr. Deneris, as well as peer-reviewed studies. The video editing system Camtasia® was used to create a 10 Provider Documentation 12 minute educational video. Camtasia® was chosen on the recommendation of Dr. Andrew Black due to its interactivity and advanced capabilities for creating a professional educational module. Once the review of literature was completed, the module was created with details on the necessary and important elements of thorough and correct documentation of different clinical scenarios. These scenarios, which included antepartum bleeding, shoulder dystocia, and pre-term labor, were selected based on literature review and discussion with ACNM representative. An e-mail inquiry was sent to the Internal Review Board (IRB) member Sarah Mumford detailing the specifics of the project. She then determined that the educational module does not meet the definition of Human Subjects Research, as it is a quality improvement measure that does not contribute to generalizable public knowledge (Appendix A). Permission to proceed with the project was granted. After the module was created in January 2017, it was sent to Ann Deneris, PhD, CNM who is an expert legal witness in medical malpractice cases for midwives. It was also sent to Andrew Black, PhD, MBA, RN, who is an educational technologies expert with an extensive IT background and expertise in nursing informatics, for feedback and revisions. The module was edited accordingly and the final module was created with voice over commentary. A pre- and post-module survey was created with the assistance of content experts, based on the learning objective of the educational module. Questions were developed with consideration of the content presented in the module, and the intended learning goals presented. Revisions were made based on the feedback and recommendations of content expert, and was delivered using Survey Monkey® which is an electronic survey delivery platform. A test group of 50 individuals in the nursing and Provider Documentation 13 midwifery field were sent the educational module, with a goal of at least 15 respondents, and they were asked to complete the pre and post-test after viewing the module. The module was sent to the ACNM national liability committee representative Mamie Guidera, CNM, MSN for consideration on the website after its completion on January 26, 2017. An application for presentation at a local ACNM affiliate meeting was submitted on December 15, 2016 and accepted for presentation by local affiliate members on February 2, 2017. Evaluation An educational module was developed and submitted for feedback and approval to project chair and ACNM representative. The module was revised as necessary based on expert feedback. The completed module was sent to a small group of participants with a pre and post module questionnaire. The pre and post-test consisted of eight questions related to module content, and one open-ended question in the post test for feedback on the module. The initial question was used to anonymously identify pre and post test respondents. (Appendix C). Evaluation of the pre- and post-tests was performed by comparing data using a paired t-test to assess learning of the participants. Feedback regarding content and format of the educational module from participants from an openended survey question was considered and revisions were incorporated based on their recommendations as appropriate. The pre- and post-test was developed with some limitations. The test was developed based on specific module objectives, and was validated by content expert review. Feedback and revisions to the questionnaire were made based on the recommendations of content experts specifically for this module. Provider Documentation 14 Initially the educational module was developed with the intention of seeking ACNM approval as a CME offering on the organization's website. However, after its creation it was deemed too concise to be considered for CME approval by the ACNM. An application was submitted and accepted for a poster presentation at a local ACNM Utah affiliate meeting in April 2017. The module will also be integrated into a course lecture regarding liability and documentation for second year nurse midwifery students at the University of Utah, as part of a didactic course. Results Twenty-two participants completed the pre-test. Nineteen participants also completed the post-test. Inclusion criteria included the completion of the pre- and posttest. The three participants who only completed the pre-test questionnaire were excluded from the data analysis. Nineteen participating nurse midwives and nurse midwife students met the inclusion criteria and the data was analyzed using the Excel data analysis program with the guidance of Dr. Andrew Black, PhD, MBA, RN. Dr. Black is the learning and data analysis content expert for this project. A statistics tutor was also utilized in the University of Utah department of mathematics, to verify the statistical analysis and interpretation. A paired t-test was performed using scores from the pre- and post-test questionnaires. Participants' scores were found to be significantly improved by 28% after viewing the module (p=.001). The average score for the pre-test was 71.25%, while the post-test average score was 99.25%. This improvement in post-test scores indicates learning occurred as a result of viewing the module. Provider Documentation 15 Feedback solicited from an open-ended survey question on the post module assessment was considered after the pre and post tests were conducted. Some participants requested more case study examples to be incorporated into the module. Several participants mentioned that standard of care examples were beneficial for their learning experience, as well as examples of specific terms to avoid in the medical record. There was varying feedback about the format of the module. Some felt that the slides advanced too quickly, while others commented that they advanced too slowly. In the future, selfcontrolled slides will be considered for ease of use for participants. Future Recommendations Effective medical documentation is a vital aspect of healthcare. Although documentation is an expected standard for nurse midwives and nurse practitioners, there is often no formal course offered in graduate curricula pertaining to the subject. This module provides basic elements of documentation training and could be expanded to provide more extensive training for nurse practitioner students as well as professional midwives. This module could also be used in its current state as an additional resource for educators teaching defensive medical documentation to reduce medical litigation among various health care professionals, including obstetrical nurses who are frequently involved in high risk obstetric scenarios, and who are not immune from litigation. The module in its current format could not be considered for CME accreditation. The module content was instead disseminated to a local ACNM affiliate organization of midwives and offered as an online resource for students and educators in the field. Given the time constraints of two semesters, an expanded module meeting CME accreditation Provider Documentation 16 standards was not feasible however, revisions to this module could be made and the product submitted for future consideration of a CME offering from the national ACNM. DNP Essentials The development of this medical documentation educational module fulfills the American Association of Colleges of Nursing (AACN) DNP essential element IV; Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care (2006). Use of technological resources allows providers to access information and continuing education to improve practice and enhance knowledge. Through educational module providers can better understand the importance of proper documentation and potentially reduce their risk of personal litigation in practice. This project also fulfills DNP essential VIII; Advance Nursing Practice, the AACN states that DNP prepared individuals will be equipped to "guide, mentor, and support other nurses to achieve excellence in nursing practice (AACN, 2006, p. 16). Charting in a specialized field like obstetrics can provide challenges, particularly for beginning nurse practitioners. This education aims to minimize some of the difficulty and uncertainty associated with charting, especially when a provider has encountered an unfavorable outcome. Conclusion Incomplete or inappropriate documentation is a commonly cited factor associated with medical litigation. Midwives in the United States are at increasing risk of litigation. Providers in obstetrics can potentially protect themselves against lawsuits with thorough and complete documentation of their care. This educational module aimed to increase Provider Documentation 17 knowledge of commonly litigated scenarios, and offer resources for improving documentation in the obstetrical field. Providers often lack information on the appropriate documentation methods, even though it is an expected standard of care in the healthcare field. Many professional organizations including ACOG, ACNM and AWHONN provide resources on appropriate documentation in high obstetrical scenarios. Despite this, many providers are still unclear on how to thoroughly document their patient care. This information was condensed and included in the educational module for students and midwifery providers. Education regarding documentation can help prevent litigation associated with documentation for midwifery providers and midwifery students. Continuing education on this subject can be beneficial in many ways. These include increased patient safety, decreased medical expenses, and greater job satisfaction. References Provider Documentation 18 Adinma, J. (2016). Litigations and the Obstetrician in Clinical Practice. Annals of Medical and Health Sciences Research, 6(2), 74-79. http://doi.org/10.4103/2141-9248.181847 American Association of Colleges of Nursing [AACN]. (2006). The essentials of doctoral education for adanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf American College of Obstetricians and Gynecologists. [ACOG] (2012). Medical Liability Climate Hurts Patients and Ob-Gyns. Retrieved from http://www.acog.org/About-ACOG/News-Room/News-Releases/2012/MedicalLiability-Climate-Hurts-Patients-and-Ob-Gyns Carpentieri, A., Lumalcuri, J., Shaw, J., & Joseph, G. (2015). Overview of the 2015 American Congress of Obstetricians and Gynecologists' Survey on professional liability. Clinical Review, 1-6. Retrieved from https://www.acog.org/-/media/Departments/ProfessionalLiability/2015PLSurveyNationalSummary11315.pdf?la=en Griffith, R. (2015). Understanding the Code: keeping accurate records. British Journal Of Community Nursing, 20(10), 511-514 4p. doi:10.12968/bjcn.2015.20.10.511 Guidera, M., McCool, W., Hanlon, A., Schuiling, K., & Smith, A. (2012). Midwives and Liability: Results from the 2009 Nationwide Survey of Certified Nurse-Midwives and Certified Midwives in the United States. Journal Of Midwifery & Women's Health, 57(4), 345-352 8p. doi:10.1111/j.1542-2011.2012.00201.x Provider Documentation 19 Isoardi, J., Spencer, L., Sinnott, M., & Eley, R. (2015). Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital. Emergency Medicine Australasia, 27(1), 6-10 5p. doi:10.1111/1742-6723.12343 Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Annals Of Internal Medicine, 162(4), 301-303 3p. doi:10.7326/M14-2128 Mayer, R., Moreno, R., & Sweller, J. (2015). E-learning theory. Retrieved from https://www.learning-theories.com/e-learning-theory-mayer-swellermoreno.html# Samadany, M. M. (2012), Does your documentation defend you?: Physician charting and medical malpractice liability. AJG. Retrieved from http://www.ajg.com/media/644145/documentation-physician-chartingmalpractice.pdf Stohl, H., Chen, J., & Jaque, J. (2012). Midwife documentation of a shoulder dystocia delivery. British Journal Of Midwifery, 20(8), 552-556 5p. Wachter, R. M. (2015). Unanticipated consequences. In The digital doctor: Hope, hype, and harm at the dawn of medicine's computer age (pp. 71-72). New York City: Wiley. Wood, S. (2011). Effective record-keeping. Practice Nurse, 39(4), 20-23 4p. Provider Documentation 20 Appendix A Institutional Review Board representative response The project you described did not appear to meet the definition of human subject research, specifically it seems more like a quality improvement measure, and it does not appear to be a systematic investigation and does not contribute to generalizable knowledge. So, this project would be considered Non-Human Subject Research. You can submit that to the IRB and we will officially tell you that, but you do not need to. Sarah Mumford (IRB Representative) Provider Documentation 21 Appendix B Doctor of Nurse Practitioner project proposal Provider Documentation 22 Provider Documentation 23 Provider Documentation 24 Provider Documentation 25 Provider Documentation 26 Provider Documentation 27 Appendix C Provider Documentation 28 Pre and post module questionnaire 1. Please provide the month and day of your mother's birthday with no dashes. Please be certain this is the same for the pre and post exam. 2. True or False: Obstetrics is in the top five of all medical specialties for litigation in the United States? 3. Medical malpractice cases require how many of the following elements to be proven in court? A professional duty to the patient A breach of duty to a patient Injury caused by a breach of duty Damages A. 3 B. 2 C. 4 D. 1 4. What is considered crucial documentation for a patient with a shoulder dystocia? A. Maternal gestation diabetes mellitus B. Umbilical cord blood gas results C. Delivery of head, anterior shoulder, posterior shoulder, and body D. Names of delivery personnel E. All of the above 5. Standard of care is defined as the level of care that another reasonable practitioner in similar circumstances would provide. Which of these is an example of a standard of care resource? A. Hospital procotol B. Peer-reviewed journal article C. ACOG position statement D. A textbook description of a procedure 6. What percentage of cases against midwives occurr in the intrapartum period, according to the 2009 survey of certified nurse midwives and certified midwives in the United States? A. 35% B. 45% C. 65% D. 55% Provider Documentation 29 7. What is considered crucial documentation for a patient who presents with antepartum bleeding in the second and third trimester? (Select all that apply.) A. Sterile speculum/vaginal exam results B. Infant feeding plan C. Despcription and estimated amount of blood loss D. Blood type 8. True or False: Incomplete or inappropriate documentation is a common contributing factor associated with litigation? 9. Which of the following terms should no longer be used in a medical record? (Select all that apply.) A. Hyperstimulation B. Category 1 Fetal heart rate tracing C. Birth asphyxia D. Gynecoid pelvis E. Vaginal exam deferred 10. A) What was the most valuable information you learned in this module? B) Please give any suggestions on ways to improve the module, or ways to make it more effective for your learning? (Post test only.) Responses: Good succinct presentation! More case study examples I learned that hospital guidelines and policies are not standard of care resources Key components of complete documentation I didn't know fetal distress shouldn't be used in the medical record. Maybe extend the time on the case study slides to ensure adequate time for reading all information. Great overall review of the topic. The format of the text was a little distracting. Try to keep it consistent throughout. Terms to avoid, and things to include in documentation. Standard of care resources I would rather be able to advance the slides at my own pace You have a great audio voice! You should do a CNM podcast :) The review of what should be documented in high risk cases Provider Documentation 30 Valuable stats on malpractice. The slides advanced too slowly This module helped me to understand why litigation occurs, why timely, specific and accurate documentation is important. Overall, I thought the module was great, the 10 minute time frame kept my attention to the module, I felt like all the necessary information was included and it the module was easy to follow and understand. Good information. I particularly liked the information about standards of care. a. crucial documentation with SD b. it was good This was so well done. So informative. I didn't realize that a prolonged labor put someone at increased risk for shoulder dystocia. I also didn't know you needed 4 elements to in malpractice cases to prove negligence. I wish every labor and delivery nurse and CNM was required to view this module. I loved it. Thank you! Appendix D Provider Documentation 31 Questionnaire data analysis Respondant ID Question 614 2 3 4 5 6 7 8 9 Pre Post Question Question Pre Score Post Score Difference 100 100 100 100 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100 1146 2 3 4 5 6 7 8 9 100 100 100 0 0 100 100 100 100 100 100 100 100 100 100 100 75 100 25 415 2 3 4 5 6 7 8 9 100 0 100 0 0 0 100 0 100 100 100 100 100 100 100 100 37.5 100 62.5 723 2 3 4 5 6 7 8 9 100 0 100 0 0 100 100 100 100 100 100 100 100 100 100 100 62.5 100 37.5 123 2 100 100 87.5 100 12.5 Provider Documentation 32 3 4 5 6 7 8 9 100 100 100 100 100 100 0 100 100 100 100 100 100 100 310 2 3 4 5 6 7 8 9 100 100 100 0 100 100 100 100 100 100 100 100 100 100 100 100 87.5 100 12.5 463 2 3 4 5 6 7 8 9 100 100 100 100 100 0 100 100 100 100 100 100 100 100 100 100 87.5 100 12.5 111 2 3 4 5 6 7 8 9 100 0 100 0 100 100 100 100 100 100 100 100 100 100 100 100 75 100 25 617 2 3 4 5 6 7 8 9 100 0 100 0 100 0 100 100 100 100 100 100 100 100 100 100 62.5 100 37.5 Provider Documentation 33 713 2 3 4 5 6 7 8 9 100 0 100 100 0 0 100 100 100 100 100 100 100 100 100 100 62.5 100 37.5 201 2 3 4 5 6 7 8 9 100 0 100 0 100 0 100 100 100 100 100 100 100 100 100 100 62.5 100 37.5 130 2 3 4 5 6 7 8 9 100 0 0 0 0 100 100 100 100 100 100 100 100 100 100 100 50 100 50 825 2 3 4 5 6 7 8 9 100 0 100 0 0 100 100 0 100 100 100 100 100 100 0 100 50 87.5 37.5 1103 2 3 4 5 6 7 100 0 100 100 100 0 100 0 100 100 100 100 75 87.5 12.5 Provider Documentation 34 8 9 100 100 100 100 120 2 3 4 5 6 7 8 9 100 0 100 100 0 100 100 100 100 100 100 100 100 100 100 100 75 100 25 1228 2 3 4 5 6 7 8 9 100 100 0 100 100 0 100 100 100 100 100 100 100 100 100 100 75 100 25 913 2 3 4 5 6 7 8 9 100 0 100 100 100 0 100 100 100 100 100 100 100 100 100 100 75 100 25 1104 2 3 4 5 6 7 8 9 100 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100 87.5 100 12.5 1007 2 3 4 5 100 0 0 100 100 100 100 100 75 100 25 6 7 8 9 Pre Score 8 Post Score 8 6 3 8 8 5 7 8 8 7 7 8 8 6 5 8 8 5 5 8 8 4 4 8 8 6 6 7 8 6 6 8 8 7 6 8 8 Pre/Post Test T= 7.5706 DF= 18 Standard 0.292 error of difference= Alpha= 0.05 P= .001 100 100 100 100 100 100 100 100 Provider Documentation 35 Appendix E Provider Documentation 36 Abstract Application for ACNM regional Affiliate meeting DNP Scholarly Project Presentation Name: Carlie Naval Specialty Track: Midwifery Title of your project: Improving Medical Documentation through Education List 3 learning objectives from your presentation: (poster or podium) Commonly litigated scenarios in obstetrics Optimal documentation to reduce potential risk of losing litigation Medical malpractice case basics, including elements needed to prove medical negligence Explain in 300 words or less how your presentation/project will advance the knowledge and practice of a Women's Health Nurse Practitioner and/or Certified Nurse-Midwife (how does this address a gap in clinical skills or knowledge, how will it improve clinical outcomes or change practice). This project is an educational module that highlights the importance of thorough medical documentation to reduce the risk of litigation in obstetrical practice. Documentation is the sole evidence that a practitioner has at their disposal to prove appropriate and timely care of a patient. The module will highlight commonly litigated scenarios, and documentation elements that should be present in order to protect a provider. There will also be education regarding medical malpractice and the elements that are presented in a court case against a provider. 4 students will be selected for podium presentation (10 minutes). All students will also present their poster at this meeting and be expected to present it to attendees. Unless otherwise notified: The ACNM regional meeting is scheduled for Thursday, April 13, 2017 in the evening at the College of Nursing. Return this by email to these recipients [e-mail]; [e-mail] Appendix F Project Poster Provider Documentation 37