LNCtips.com: Go with the Flow

Go with the flow. Flow sheets, that is. You know the kind of nursing records I'm talking about. These forms combine 24 hours worth of information on a single (or sometimes a double or triple) page. Flow sheets were a wonderful invention for staff nurses, physical therapists, and other healthcare providers because this form of charting is much quicker to use than narrative notes. 

But this boon for healthcare providers can be a bane for legal nurse consultants. There's a ton of information on each flow sheet. How do LNCs review these records and summarize them for attorneys? Let's take a look at ways to quickly and effectively analyze flow sheets. Yes, they're still around, even with many health providers switching to electronic medical records.

Before you start, determine if all of the flow sheets are important to the case. They're important if they relate to the plaintiff's allegations and claimed damages or describe prior history that can be linked to the allegations. For example, if a plaintiff's allegation is that an impending stroke was missed by caregivers, important flow sheets would be neurological assessments and check lists from all medical records, but particularly from the time of the stroke. For damages, the after-effects of the stroke (such as vision problems or hemiplegia) need to be noted at the time of the stroke and in all medical records after the event.

If the flow sheets are important to the case, note the patient's baseline assessment, including the time of the baseline. Are the assessment and the time consistent with plaintiff allegations? You'll want to transfer the baseline information and your analysis to your medical chronology or summary.

When you're looking at a lot of information on a page, it's easy to overlook important facts such as changes in condition. So you'll want a way to note these changes to help you when you're summarizing. For paper medical records, use a yellow highlighter to mark every change on the flow sheet as seen in the photo below.

For electronic medical records, you'll need a Professional or Standard version of Adobe Acrobat (not Reader).  You can highlight text (but not handwriting) with these versions of Acrobat. To note handwritten entries, you can draw a rectangle around changes as shown in the photo below.

You may need to place several pages side-by-side to note changes from shift-to-shift or day-to-day.

While you're reviewing the flow sheet, note when the changes occurred. Were drastic changes documented at the start of the oncoming shift? I'm always suspicious when a patient's assessment is unchanged for 8 to 12 hours and then a drastic change is documented on the next shift. It implies that the presonnel on the off-going shift were inattentive.

Did the changes occur while the patient was off the unit? If the patient was in Radiology, for example, it may imply a lack of monitoring in that department if the patient returned with changes. Or there may have been monitoring that was documented in a different part of the medical record.

Once you've highlighted significant changes, correlate them to other sections of the medical record. Was anyone notified of  the changes? Were there any new orders? Were the orders carried out? Were they effective?

When you're summarizing the flow sheets, you can now quickly identify the highlighted areas of the records and incorporate them into your report.

...Katy Jones