I received a question from Mr. Tharen J. Leesch, CVT-AAS, from Florida Hospital, Zephyrhills, Florida, who asked, “What are the standards for documentation in a cath lab report? What should be in it, how specific should it be, and what is too specific?”
When charting and writing medical notes, we have to ask for whom are the notes written. Notes are written for 3 groups of people: 1) the lawyers who may become involved with medical legal problems; 2) the hospital billing and quality control people, and 3) medical caregivers. This last group depends on the use of the notes the least, because care issues about a specific patient are usually transmitted personally by verbal report. Occasionally, the notes from the ER or CCU nurses about what medications were given are important to the cath lab during transfer for the acute patient. With these groups in mind, what is a legally and clinically sufficient charting note?
As a disclaimer, I am no lawyer and at this time I know of no formal guideline or standard for note writing in the cath lab (or anywhere else). Mr. Leesch found only one document that even refers to charting in the cath lab.1 Adequate charting is recording information that is proper for the protection of the patient, staff and institution. “Writing a note” is a skill learned as a tradition in the lab, passed along from older to younger cath staff. Few CVT programs offer formal training on this subject. For those of you who have the 2nd edition of The Cath Lab Handbook (blue cover, spiral-bound, 1995), Chapter 10 is entitled “Documentation in the catheterization laboratory,” authored by Aileen O’Rourke, JD and Diane Brown, JD. This chapter discusses at length general issues with regard to medical documentation and specific issues with regard to the cath lab, and might serve as a reference.
For each of the three groups of readers mentioned above, let’s see what each is looking for. The lawyers want to know what, when, how and if available, why something was or was not done. This information is compared to what should have been in done in the same setting. They hope to use the information to address questions on the standards of care and medical errors. The note is used for in-house legal risk managers in review of potential malpractice complaints and their defense. The records become a major factor in determining outcome of any litigation, but also provide evidence for appropriate treatment, billing, quality, behavior, and communication.
The billing and quality assurance personnel reading your note need to understand what has been done for the patient, and the indications for the procedures and how they were performed.
The medical caregivers want to know what the status of the patient is at the time of the procedure. They often, but not always, rely on the notes you write. Proper charting in the cardiac cath lab is no different from charting in any other area of the hospital.
Where to start? All documentation should have clear legibility and organization. Your entry should be signed with your name (for best clarity, both scripted and printed) and your work status (RN, LPN, and CVT). The date and time of every entry are required. Sloppy charting is often equated with poor care. Accurate documentation of the events means just the facts; not what you wanted to happen but what actually happened. Use of symbols and abbreviations is discouraged. Abbreviations can be misinterpreted or have more than one meaning. When in doubt, employ the full word. The description of any activities in the cath lab should be strictly factual with an observation of what you saw and did, rather than what you think you saw or should have been done. No editorializing.
Chart the delivery of the care after it occurs and not beforehand. Never make an entry in anticipation of something being done. Never leave any blank spaces to be filled in at a future time.
If a charting error is made, do not obliterate the error or erase it, rather, simply draw a line through it, add the date, time and your initials, write the reason for the error and note the correction. Most hospitals and cath labs have a policy that addresses the method of charting errors.
Despite having an electronic medical record (e-record) in the cath lab, the number of documents that need to be managed by nurses’ hands remains about the same. For example, in our lab, nurses must document on the airway protection/conscious sedation sheet, the consent form, the equipment list and the brief tracking record of hospital transit. The medical order sheets also are often part of e-record. In addition to reviewing and signing the e-record, admission, intraprocedural and discharge data needs to be entered in the appropriate locations for the appropriate times and events.
Documentation of medications administration is critical. For any medication given in the cath lab, the name, dose, route of administration, site of injection and time of administration is the minimal information needed. For further detail, charting the rate of infusion, the type of needle, the IV site, and type of IV is helpful. If special filters, infusion devices or monitoring equipment are used, this should also be included in the record.
For administration of blood products, signatures of two persons checking the blood and blood products may be required. Recording the number of units of packed blood cells is also critical. If intravenous lines are started in a cath lab, note the date and time of initiation on the securing bandage, so that the receiving team can understand how long that intravenous line has been in place.
Please see Table 1 for minimal documentation in the cardiac cath lab.
Documentation of an event requiring an incident report
Each facility should have a policy outlining the requirement of incident or occurrence reporting. An unanticipated, unexpected event involving a patient that may result or did result in injury to the patient needs to be reported. Some of these events are listed in Table 2.
Product or equipment failure
Documentation of product liability in the cath lab is required. Chart the products used in all procedures by name, lot number, and specific identifying information. Intravascular device failure may constitute an incident report which must be sent to both the hospital and device manufacturer. A minimal standard for cardiac catheterization requires complete documentation of any equipment failure. When in doubt about product failure, a call to your risk assessment department of the hospital is in order.
What should go into a cath report?
Cardiac catheterization reports can be generated in two ways. One is to have the physician dictate the report from the records available and after review of the angiograms, input the descriptive information into the report. The second method is to have the electronic record computer generate the report. The physician then reviews and edits the report, and finalizes the information for distribution.
Of course, cardiac catheterization reports are individualized for the physician, laboratory and procedures performed. Here is one example of a typical procedure note from our institution. The sections of the report are as follows:
1. Patient information, date and time of the procedure
2. Procedures performed (for example, left heart catheterization, coronary angiography, left ventriculography)
3. Operators performing the procedure, including support staff
4. Technique used for the procedures (Indicate access site equipment used, size catheters, and number of views. Note any difficulties with projections or imaging, changing of catheters for different equipment, angiography the access site, access closure device.)
5. Findings of the procedure (hemodynamics, coronary angiography, left ventriculography, percutaneous coronary intervention, femoral angiography, other results of imaging studies)
6. Complications, procedure and fluoroscopy time, amount of x-ray contrast used
7. Final impression of results 8. Recommendations for patient management based on the results
The e-record has eliminated much of the drudgery of note writing, but there will always be paper that needs to be pushed (written) by the cath staff. Be clear, concise and accurate. As one quality assurance member reported to me, and it is worth remembering, “To err is human, to document is divine.”
1. Bashore TM, Bates ER, Kern MJ, et al. American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. JACC June 2001; 37(8):2170-2214.