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On a patient history form, is it legal for us to just write in the heading area that the patient denies any of the below symptoms, instead of checking yes or no to every symptom?

Monday April 8, 2013
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Question:

Dear Nancy,

We use a computerized health history form for information on a patient’s history. There are different headings, such as cardiac, with a number of symptoms listed below each one. A yes or no answer is required and an explanation, if applicable. If we answer yes or no to every symptom and we need to print it out, it prints up to three pages — we are trying to conserve paper. Is it legal for us to just write in the heading area that the patient denies any of the below symptoms, instead of checking yes or no to every symptom?

Grace



Nancy Brent replies:

Dear Grace,

It would seem that if the form had some sort of instruction stating that if the patient answers no to all of the below symptoms and there is a box to check to indicate this, then that should be adequate documentation. This would allow the reader to see that for the cardiac assessment, the patient had none of the symptoms listed.

When using such forms, often it is best to have a policy that states the checklist is acceptable as adopted, but if the patient reveals symptoms not listed on the form, that information needs to be documented, either on a space provided on the form, or in the nursing narrative. In other words, the list of symptoms should not be used as a complete list, especially if the patient mentions another symptom or complaint.

By the way, the list of symptoms under a cardiac heading should be composed of those symptoms commonly experienced by those with a cardiac problem, and must be based on evidence-based research.

There is a wealth of information on nursing documentation with checklists and forms. You might want to review some of them for information, forms and checklists that already have been developed. One interesting book to think about reviewing is “Soaring To Success: Taking Crew Resource Management From The Cockpit To The Nursing Unit,” Sculli and Sine (HCPro, Inc. Danvers, MA, 2011). You can read more about this text at: www.hcmarketplace.com/prod-8993/Soaring-to-Success.html.

Sincerely,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.