The Pelican - LSNA Nursing News & Updates
Table of Contents
From Your President Elevating Nursing in Louisiana: A Call to Action
From Your Executive Director Making the Most of March
District News New Orleans District Nurses Association, District VII Baton District Nurses Association Annual Meeting
Upcoming Events 2025 LSNA Membership Assembly Poster Presentations Planned for Membership Assembly Candidates for LSNA Office 2025 2025 Nurses Day at the Capitol
Nursing News New Board of Directors LANPAC Announcement Baton Rouge Local Nursing Community Enjoys Networking Event Nurse Spotlight: Healthcare Documentation
Education LSNA Trafficking Task Force
Join LSNA
March 2025
The Pelican - LSNA Monthly Nursing News & Updates
From Your President
Elevating Nursing in Louisiana: A Call to Action
Benita N. Chatmon, PhD, MSN, RN, CNE

During the month of February, we had the privilege of celebrating and in some cases, discovering, the extraordinary Black nurses, nurse educators, and nurse leaders whose legacies have shaped the nursing profession in Louisiana. Ray A. Bias, Jacqueline Hill, Sandra Brown, Terrie Sterling, Cynthia Bieniemy, Deborah Ford, and Rita Miller were among the many trailblazers whose dedication and advocacy have left an indelible mark on our state. Their commitment to excellence, leadership, and service reminds us that nursing is not just a profession. Nursing is a calling to uplift, innovate, and lead.

But our celebration does not stop here. We remain steadfast in honoring all nurses who have worked tirelessly to elevate healthcare in Louisiana. In the coming weeks, you will have the opportunity to recognize and nominate a nurse who inspires you. Throughout May (National Nurses Month), we will spotlight these remarkable individuals on our social media platforms. This is your chance to celebrate the change-makers, the mentors, the advocates, and the quiet heroes who dedicate their lives to patient care and professional advancement.

Your Voice, Your Impact: Make It Count

We stand at a pivotal moment where your engagement is more critical than ever. In just a few weeks, LSNA will convene for our Membership Assembly, where District Delegates will shape the future of our organization by voting on key bylaws and resolutions. These decisions determine the direction and strategy of LSNA and, by extension, the nursing profession in Louisiana. Your voice is your power, let's use it!

On April 30, 2025, we take our collective voice to the Capitol for Nurses Day. This is more than an event. Nurses Day at the Capitol is an opportunity to influence policy, advocate for nursing, and ensure our profession is heard at the highest levels of government. I am especially proud that our inaugural Health Policy Fellows will be applying their expertise that day, helping to lead and support legislative efforts. This is what action looks like. This is what impact feels like.

Honoring Excellence: The Future of Nursing Leadership

Following Nurses Day at the Capitol, we will shine a light on the next generation of leaders at our Forty Under Forty Dinner Reception. This evening will not only celebrate the rising stars of nursing but also recognize our Health Policy Fellows and new award recipients. These individuals represent the future of healthcare, and their achievements remind us that nursing is not just about care, it's about leadership, advocacy, and transformation.

Now is the Time: Engage, Elevate, and Lead

I don't just want you to join LSNA. I want you to engage, influence, and lead. Consider serving on a committee, attending a board meeting, or getting involved at the district level. A strong LSNA depends on strong districts, and we need your ideas, your passion, and your commitment to propel us forward.

Nursing is at a crossroads. The decisions we make today will define the profession for years to come. Commit today to making LSNA the organization of choice; not just for yourself, but for the future of nursing in Louisiana.

Your time is now. Will you step up?

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From Your Executive Director
Making the Most of March
Ahnyel Burkes, DNP, RN-BC , NEA-BC

March is shaping up to be a very busy and exciting month for LSNA! I look forward to seeing everyone at the 2025 Membership Assembly at the end of the month. This pivotal meeting will not only bring together nursing professionals from across the state, but it will also set the stage for LSNA’s future. During the Assembly, members will elect new leadership and vote on key initiatives that will shape the organization’s focus for the next two years.

In addition to the essential business meeting, LSNA has planned a day dedicated to professional development, featuring insights from esteemed local and national experts. If you haven’t registered yet, there’s still time to join us! Register here. Be sure to check out the agenda to see what’s in store.

Sponsorship Opportunities - Click Here

Announcing the 2025 40 Under 40 Honorees

We are thrilled to celebrate the outstanding nurses selected for the 2025 40 Under 40 Awards. These individuals exemplify excellence, innovation, and leadership in the nursing profession. Join us in honoring them at our special event!

Click an image to expand viewer.
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Purchase Tickets Here

Explore Sponsorship Opportunities

Stay Connected with LSNA

We are excited to announce the upcoming launch of the LSNA mobile application this month! This new platform will help nurses and student nurses stay informed and engaged with LSNA activities, advocacy efforts, and professional development opportunities. Stay tuned for updates!

Get Involved in Nurse Advocacy

Nurse advocacy remains a key priority for LSNA, and we have two impactful events where you can make your voice heard:

Advocacy Day

Engage with policymakers and learn how to be an effective advocate for the nursing profession. Register Here

Nurses Day at the Capitol

Join fellow nurses at the Louisiana State Capitol to demonstrate the strength and influence of our profession. Register Here-https://lsna.nursingnetwork.com/nursing-events/145541-nurses-day-at-the-capitol-2025#!registration

LSNA Store

Show your LSNA pride with our exclusive merchandise! Check out our latest apparel and accessories designed for nursing professionals. Visit the LSNA Store today! 

March is a time of growth, change, and action. I encourage all LSNA members to take advantage of these incredible opportunities for networking, professional development, and advocacy. Let’s make the most of this month together!

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District News
New Orleans District Nurses Association, District VII
Dr. Kendra M. Barrier, PhD, MSN, RN, CNE

New Orleans District Nurses Association, District VII

Dr. Kendra M. Barrier

President, NODNA

NEW OFFICERS

Chantel Moffett, MBA, MSN, CPHQ -- Treasurer

Charette Thomas, RN, BSN, NPD-BC, CCHC -- Director of Events

NODNA STUDENT LEADERSHIP AWARDS

NODNA also sponsored four (4) Student Leadership Awards to graduating seniors of the New Orleans District Schools of Nursing:

NODNA LEADERSHIP POSITIONS

NODNA is seeking an energetic person to fill our secretary position. Anyone interested in a leadership or a committee position, please contact Dr. Kendra M. Barrier, president@nolanurses.com.

MEETINGS & PROGRAMS

NODNA's membership meetings are scheduled for the second Wednesday of the month. Please go to NursingNetwork.com to view the 2025 operational calendar. Please follow us Facebook, Instagram, LinkedIn, and Twitter for programming updates. NODNA provides nurses an opportunity to earn CE Credit and network with other nurses throughout the New Orleans Metro Area.

I would like to thank every nurse for their membership. The Board of Directors and I want our members to know that each member is in our daily thoughts as you continue to provide excellent care. NODNA appreciates everything you do!

Thank you for your support.

All the best,

Kendra M. Barrier, PhD, MSN, RN, CNE

Baton District Nurses Association Annual Meeting

The Baton District Nurses Association held their annual meeting on January 16, 2025, at Rouj Creole restaurant on Bluebonnet. Heather Runnels the outgoing President led the meeting. Board members gave their annual reports, and the nominating committee reported the election results for President-elect, Vice President, Treasurer, Recording Secretary, Health Policy board member and Public Relations board member. After the business meeting and dinner, the installation of the new board was held.

Pictured are the newly installed board members. From left to right:  Wendy Singleton -- President, Staci Sullivan -- President elect, Allyson Bennett -- Vice President, Emily Richard -- Treasurer, Terri Edward Thompson -- Recording Secretary, Carla Harmon -- Health Policy and Laura Gomez -- Public Relations.

We are currently asking members of the Baton Rouge District to contact us at presidentbrdnalmd@gmail.com if you would be interested in joining one of our committees. The following are the standing committees:

  • Archives

  • Bylaws

  • Finance

  • Health Policy

  • Membership

  • Program

  • Professional Practice

  • Publica Relations

For more information about the committee responsibilities, membership meetings and other events please visit our website, https://brdna.nursingnetwork.com/

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Upcoming Events
2025 LSNA Membership Assembly
Power of Nurses as Leaders, Advocates, and Innovators
Benita N. Chatmon, PhD, MSN, RN, CNE

The Louisiana State Nurses Association (LSNA) Membership Assembly is just around the corner, and we are excited to welcome you to this year's gathering of nursing leaders, advocates, and innovators! Mark your calendars for March 26-27, 2025, as we convene at the Baton Rouge Marriott for an event focused on the "Power of Nurses as Leaders, Advocates, and Innovators."

This year, we are honored to welcome Jennifer Mensik Kennedy, PhD, RN, NEA-BC, FAAN, President of the American Nurses Association, as our keynote speaker! Her insights and leadership will inspire and empower us as we continue shaping the future of nursing in Louisiana.

To ensure an engaging and effective Membership Assembly, we encourage all delegates to utilize the "Delegate Corner" as a resource for preparation. The agenda includes key discussions, bylaws amendments, and resolutions that require your review. Understanding these topics in advance will allow for more meaningful participation and a smoother, more efficient Assembly.

Whether you are a returning delegate or new to the Membership Assembly, attending the Delegate Orientation is highly recommended. This session will provide valuable insights into your role and responsibilities, ensuring you are well-prepared to engage in discussions and decision-making. If you are unable to attend the zoom session, don't worry, the orientation will be recorded and made available for later viewing.

Stay Informed: Review Bylaws Amendments & Resolutions

We have bylaws amendments and several resolutions on the agenda that require your attention. Please take the time to review these documents before the Assembly and reach out to the respective committee chairs if you have any questions. Your input is essential in shaping LSNA's strategic direction and ensuring our policies reflect the needs of Louisiana nurses.

The 2025 LSNA Membership Assembly is more than just a meeting. You will also get the opportunity to spend a day engaging in professional development and connecting and collaborating with colleagues. Your voice and participation are crucial in defining the future of nursing in our state. We look forward to seeing you in Baton Rouge for two days of insightful discussions, professional growth, and advocacy for our profession!

LSNA_Minutes_-_MA_2023_-_Day_1.pdf
LSNA_Minutes_-_MA_2023_-_Day_2.pdf
Membership_Assembly_Rules_2025.pdf
Poster Presentations Planned for Membership Assembly

Authors

Title of Poster

Dr. Stephanie P. Arceneaux 

Education of Nursing Students on Human Trafficking Improves Knowledge and Confidence 

Gracie Latiolais 

TyreAnna Saddler 

Trisha Barnaba 

Kadie Clostio 

Olivia Edney 

Sweet Dreams: Safe Infant Sleep 

Kalie Robin 

Piper Prouet 

Kaitlyn Picard 

Jessica Lopez 

Be Smart, Do Your Part, and Protect Your Heart: Prevention of Sudden Cardiac Arrest in Young Athletes 

Danika Mills BSN, RN 

Iesha Bethley, MSN, CMSRN, RN 

Nicholas Gros MSN, RN 

Unlisted

Sarah Wilson, BSN, CMSRN, RN 

Tiffany Huffman, MSN, RN 

Use of RCA to Identify Potential Fall Cause and Corrective Action Plan 

Bridget Morales, MSN, RN 

Elizabeth Hoover, MSN, RN 

Integrating “Compassionate Connections” in Safe Patient Handoffs 

Fiona Winterbottom DNP, ACNS BC 

  1. Automating Advanced Care Planning into Daily Clinical Workflows
  2. Reducing Clinical Deterioration through Interoperability and Smart Staffing 

Fiona Winterbottom DNP, ACNS BC 

Melinda Stretzinger RN, CCRN 

Rachelle Longo RN, MHA 

Implementation of a Medical-Surgical Virtual Nurse Discharge in Community Hospitals of a Large Healthcare System 

Demi Gautreaux, MSN-Ed, RN 

Yvette Boudreaux, RN 

Connect the Dots: Using Student-centered Learning to Decrease Unlicensed Assistive Nursing Personnel Turnover Rates 

Rebekah Warner BSN, RN 

Brando Anderson BSN, RN 

Iesha Bethley MSN, CMSRN 

An Interdisciplinary Approach to address Social Determinants of Health (SDOH) in a Hospital Setting 

Emma Harrell 

Madelyn Cordova 

Katelyn Bedwell 

Taylar Joseph 

Destiny Lewis 

Learn the Signs, Act Early; Early Childhood Development Milestones 

Ava Watts 

Nadia Spain 

Mercy Oshiokhale 

Gracie Welch 

Erica Rodriguez 

Milk Matters: Smart choices for Mom's with HIV 

Jeanne Manuel, MSN, RN, CNE 

Jennifer Allain, DNP, APRN, FNP-C, PMHNP-BC 

Sharonda Johnson, DNP, RN 

Arielle St. Romain, DNP, RN, CNEcl 

Tricia Templet, DNP, RN, CPNP-PC, FNP-C 

Generating a Diverse Nursing Faculty Workforce: A Guide for Academic Leadership 

Dr. Lxchelle Arceneaux 

Kayla Cusachs 

Wireless Wearable Devices Revolutionize Real-Time Vital Sign Monitoring in Medical-Surgical Units: Transforming Patient Care 

Candidates for LSNA Office 2025

Meet your amazing Candidates for LSNA Board Positions!

Click on the Candidate's name to watch their brief interview by members of the LSNA Nominating Committee.

President-Elect

  • Cynthia Ingram  
  • Heather Runnells  

Secretary

  • Iesha Bethley  
  • Georgia Johnson   

Treasurer

  • Denise Jones  
  • Elsie Meaux  

Director of Leadership and Nursing Professional Development

  • Lxchelle Arceneaux  
  • Tricia Broussard  

Director of Organizational Advancement

  • Miguel Jolivette  

Nominating Committee

  • Tren Garbo   
  • Tamara Manns   
  • Karen Wyble   
2025 Nurses Day at the Capitol

Join fellow nurses at the Louisiana State Capitol to demonstrate the strength and influence of our profession. Register Here

Nursing News
New Board of Directors
Georgia Johnson, MS, RN, NEA-BC - LSNA Secretary & LSNA Award Committee Chair

We are pleased to announce our Board of Directors' positions for 25-26:

President: Teresa Krutzfeldt (new) Dir. Transition to Practice: Debbie Carambat (new)

Vice President: Yvette Bertaut (con't) Dir. of Publicity: Georgia Johnson (con't)

Secretary: Jill Breazeal (con't) Program Dir.: Kay Sabadie (con't) Treasurer: Denise Campbell (new)

Director of Social Media: Tiffany Swoboda

Director of Operations: Cindy Ingram (change)

Director of Community Service: Ecoee Rooney (new) 

Director of Recognition: Elizabeth "Tren" Garbo (re-elected) 

Director-at-large: Allison Maestri (change)

Director-at-large: James Foley (con't)

Director-at-large: Laura Lucky (new)

Director-at large: Charlotte Foucha (change)

Director of Advocacy: Michelle Hoskins (re-elected)

Director Emeritus: Janice Augustine (con't)

Left to Right: Allison Maestri, Jill Breazeal, Debbie Carambat, Ecoee Rooney, Teresa Krutzfeldt, James Foley,Georgia Johnson, Kay Sabadie, Laura Lucky, Charlotte Fouche, Tiffany Swoboda

MEMBERSHIP: We again have had great success with our Membership Program. We have had a robust Membership R/R Program for several years AEB consistent gain in membership from 95 in 2017 to 185 in 2024. We have received recognition for this growth at the state level by receiving the following "Leading Way" Membership Awards at Membership Assembly:

  • 2019 - Overall gain in Membership

  • 2021- Most New Graduates gained

  • 2023 - Overall gain in Membership

The greatest factor is an engaged BOD which has been expanded significantly to create leadership opportunities. In the past 2 years our BOD increased from eleven to sixteen by adding a Director of Advocacy, Director of Recognition, Director of Social Media, and two additional Directors-at-large. This expansion has been in response to members that want to be involved in the leadership of the organization. This BOD engagement combined with our membership directed activities have led to our successful growth. The Membership Program consists of 3 components - Communication, Deliverables, and working the monthly LSNA list

EXPANSION: Inactive LSNA Districts have begun to merge with an adjoining active district. Efforts were initiated last year to merge District 11 (Tangipahoa DNA) and our Dist. 3. As of January, there will be an expanded Northshore District Nurses Association that will now include Washington, St. Tammany and Tangipahoa parishes. We have welcomed forty- three members from Dist.11 by each Director introducing their assigned program to our new members. 

Additionally, we established a new delegate-at-large position to specifically represent Tangipahoa since our 2025 election had closed. We have started work to integrate these nurses with our NDNA activities and promote their representation.

MEMBERSHIP ASSEMBLY: Now that our delegate allotment has increased to twenty-five, it will be a challenge to achieve a full delegation like we have in the past. The NDNA BOD has completed the submission of district nominations for the LSNA "Leading Way" Awards. We have received an award at every Membership Assembly. There are more Awards available this year. We hope to continue this trend.

LASN: NDNA looks forward to working with the newly reorganized Louisiana Student Nurses Association to develop and grow our chapters on the Northshore. Engaging students and recruiting new graduates to join within six months of graduation to receive a 50% LSNA membership discount for two years is an important initiative of every district. New grads are the future of our profession and the association.

FEBRUARY MEETING: We kicked off the new year with a great turnout for our first mtg with twenty-three attendees. Business meeting included 2025 Strategic Plan, discussion of planned community events, rotating meetings between facilities in the three-parish area, recognition of outgoing president, Charlotte Fouche, review of draft resolution on "Promoting Evidence-based Vaccines". 

Our meeting ended with a great CNE presentation by Raymond J Devlin, DNP, CRNA, Anesthesia Manager, Our Lady of the Angels Hospital on the topic: " the Repurposing of Lidocaine for Prevention and Treatment of Acute Lung Injury",

LANPAC Announcement
Elsie B. Meaux, RN, BSN, MHA - Chair of LANPAC

We would like to congratulate our new officers to LANPAC, Ashley Wilkerson as Vice Chair and Olivia Giles begins her second term as Secretary/Treasurer. Completing the second year of our terms are Elsie Meaux as Chair, Kourtland Adams as Member at Large and Ahnyel Burkes as LSNA liaison. Nominating Committee members are Charlotte Thomas, Ivory Davis and Danielle Guillory. Congratulations to all and we look forward to a great year.

Many things are in the works for LANPAC. We are very excited to be re-introducing the LANPAC Dinner at this year's Membership Assembly. It will be on Wednesday, March 26th and we hope many of you can attend this event and help not only spread the word about LANPAC but also to help increase our contributor base. It is only though increasing our number of contributors and contributions that we are able to lobby for legislation that we support (or oppose) for nursing.

The LANPAC board voted to endorse Rep Brach Myers and Rep Larry Selder in the Senate races in their districts to be held in February. As elections draw near in the fall, we will again evaluate the qualifications, voting records, and views on nursing issues to provide support for their canadicy.

LANPAC will be participating in both the Advocacy Day on April 25 and Nurse Day at the Capitol. We hope that many of you can join us as we help bring attention to the needs of nurses in our state. Below are the ways you too can become a contributor to to LANPAC. I hope you will take a minute to complete the contribution and help make Nurses a priority in Louisiana.

Donate Today

PayPal: lanpac1986@gmail.com - click on Family and Friends

Online: Click Here

Check: Mail to LANPAC 512 Pebble Dr. Haughton, LA 71037

Or us QR code to the right

Baton Rouge Local Nursing Community Enjoys Networking Event

The local nursing community, including nursing students, gathered on February 6,2025, for a unique and relaxing networking event, hosted by the Baton Rouge General Medical Center in collaboration with the Baton Rouge District Nurses Association. 

This event provided a refreshing change of pace, focusing on informal interactions and stress-free networking among nurses, nursing students, and other healthcare professionals.

Unlike traditional networking events, this gathering featured no speakers or formal presentations. Instead, attendees enjoyed casual activities designed to foster connections and camaraderie. The event was held at a local bistro and included social mixers, group discussions, and interactive activities, all aimed at creating a welcoming and supportive environment. 

Participants appreciated the opportunity to unwind and engage in meaningful conversations with their peers. Students found the event to be highly beneficial, as they were able to meet experienced professionals and get advice in a more informal setting.

The event's organizers were pleased with the positive feedback and the strong sense of community that emerged. The event created a space where everyone could feel relaxed and truly connect with one another. It's clear that this approach resonated with attendees, and the organizations are excited to continue to collaborate and plan more events like this in the future.

For more information about upcoming events and how to get involved, please visit brdna.nursingnetwork.com

Nurse Spotlight: Healthcare Documentation
Nurses Service Organization

Nurses Service Organization (NSO), in collaboration with CNA, has published our 4th Edition of the NSO/CNA Nurse Liability Claim Report. It includes statistical data and case scenarios from CNA claim files, as well as risk management recommendations designed to help nurses reduce their malpractice exposures and improve patient safety.

You may access the complete report, and additional Risk Control Spotlights, at: www.nso.com/nurseclaimreport.

This Nurse Spotlight focuses the analysis and risk recommendations regarding one of the most significant topics in the report and for nursing professionals: Healthcare Documentation.

Nursing Allegations Related to Healthcare Documentation

While documenting care represents a critical component of nursing processes and standards, the electronic health record [EHR] has posed a level of complexity for nurses who are often challenged with why, how, what and where to document in a patient’s EHR.

Documentation deficiencies are contributing factors to many nurse professional liability claims, as well as license protection matters. However, in the 4th Edition of the NSO/CNA Nurse Liability Claim Report, failure to document or falsifying documentation closed claims, as an allegation of professional liability, increased in distribution and severity when compared to the 2011 closed claim report and the 2015 closed claim report. Below is an example of a professional liability claim asserted against a nurse due to the failure to document:

Nurse Legal Case Study: Absence of documentation in violation of nursing standard of care

The patient was admitted to a rehabilitation facility after undergoing a right hip arthroplasty. Due to the patient’s other co-morbidities, her rehabilitation and recovery was slow and difficult. The patient’s health continued to deteriorate during her admission, until her death four months following admission. After the death of the patient, the family (plaintiffs) filed a complaint with the Department of Health (DOH) regarding the patient’s care at the facility.

The DOH investigated the complaint and cited 13 violations in the nursing standard of care. In particular, the DOH was critical of the absence of documentation related to care plans for the Foley catheter, the patient’s weight loss (from 93 to 77 pounds over four months), and neither shower nor self-care was documented for a timespan of more than five weeks. The insured registered nurse (RN) was the facility’s wound care nurse, and the DOH’s investigation found several violations of the nursing standard of care specific to the RN’s lack of documentation. First, the DON found a lack of documentation regarding a nursing incision wound for a period of approximately three weeks. The RN told the DOH surveyor that daily assessments were performed during that time, but, since the wound care orders were to leave the right hip incision wound open to air, no treatment was performed, so the RN did not document anything. The patient also had a left heel pressure injury that was not healing, and the RN agreed that this non-healing injury had not been appropriately assessed or documented. Moreover, the director of nursing informed the DOH surveyor that the RN was required to perform weekly assessments on all patients in the facility. However, none were noted in the patient’s healthcare information records during a three-month period.

After seeing the DOH report, the family sued the facility and sued the insured RN separately. Knowing the challenges of the missing documentation and the negative DOH report, mediation was proposed with the plaintiffs. The total incurred amount to defend and settle this case on behalf of the insured RN was greater than $270,000

In the 2011 closed claim report, 0.2 percent ($31,250) of all closed claims were related to inadequate or inappropriate documentation as the primary allegation. This data increased slightly to 0.5 percent ($139,920) in the 2015 closed claim report. Respectively, in the 2020 closed claim report, documentation allegations represent 2.0 percent ($238,761) of all closed claims.

Figure 1 demonstrates the increase in severity of professional liability claims related to documentation allegations. While these professional liability claims occur infrequently in the 2011, 2015 and 2020 closed claim analyses, allegations related to documentation failures can be difficult to defend and often result in a license protection defense matter against the nurse.

A license protection matter and a professional liability claim reflect a number of differences. First, a license protection matter only involves the cost of providing legal representation to defend the nurse before a regulatory agency or State Board of Nursing (SBON). On the other hand, professional liability claims include an indemnity or settlement payment. Second, license protection matters asserted against a nurse’s license to practice may or may not involve allegations related to patient treatment and care. The Nurse Spotlight: Defending Your License provides an overview of the role of the State Board of Nursing in the legal/regulatory system, describes the disciplinary process, and imparts helpful recommendations on defending yourself if you were to receive a complaint summons.

Figure 2 displays license protection matters with defense expense payments that involve allegations related to documentation. Documentation as a primary allegation comprises 9.7 percent of all license protection matters in the Nurse Liability Claim Report: 4th Edition. Approximately half of the license protection matters related to documentation involve an allegation of fraudulent or falsified patient care or billing records (4.8 percent).

A nurse’s license is one’s livelihood, and its protection is paramount. A nurse’s practice and behavior is expected to be safe, competent, ethical and in compliance with applicable laws and rules. However, when a complaint is filed, nurses must be equipped with the resources to adequately defend themselves. Being unprepared may represent the difference between a nurse retaining or losing the license to practice, a suspension or fine.

The False Claims Act

While documentation deficiencies may result in a professional liability claim and/or a license protections matter, nurses also may be subject to federal and state sanctions for knowingly falsifying healthcare documentation under the federal False Claims Act (FCA). The FCA imposes liability on any person who submits a claim to the federal government that they know (or should have known) is false. An example may be a healthcare provider who submits a bill to Medicare for medical services they know they have not provided. The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. For additional information on fraud and abuse laws, please see the Office of Inspector General’s provider education materials on Fraud & Abuse Laws.

Healthcare Documentation: Minimizing Risks, Maximizing Benefits

NSO/CNA is often asked about documentation risks and recommendations to minimize those risks. Nurses are certainly aware that there are patient healthcare documenting fundamentals. The healthcare information record is a legal document that is an essential tool to:

  • Document the services provided regarding the patient’s illness or injury, response to treatment, and caregiver decisions;
  • Communicate documented information about the patient’s plan of care and outcomes to the health care team
  • Communicate information to other nursing professionals and healthcare providers;
  • Support the appropriate information for billing coding; and
  • Serve as the organization’s business and legal

Because complete, accurate and legible healthcare records constitute an essential risk management measure, nurses should maintain proper documentation practices and follow facility policies and procedures governing appropriate and comprehensive records documentation. The facility’s healthcare record documentation policies and procedures should address, at a minimum:

  • Correcting documentation errors;
  • Delineating appropriate use of the copy and paste function in the electronic healthcare record;
  • Documenting practices during electronic system failures or outages (“down-time”);
  • Maintaining patient confidentiality;
  • Releasing patient healthcare information records and auditing practices; and
  • Procedures for late or delayed

Risk Management Recommendations: Documentation

Maintaining a consistent, professional patient healthcare information record is integral to providing quality patient care, ensuring consistent communication among all professionals caring for the patient, documenting patient care outcomes and response and establishing the basis for an effective defense in the event of litigation. The following guidelines can help reduce risk:

Documentation – Clinical Content

  • Document nursing actions in accordance with facility requirements and patient needs, capturing the following information as clinically indicated:
    • results of each nursing assessment
    • pertinent nursing observations
    • patient complaints or concerns
    • significant changes in the patient’s condition
    • any change in the patient’s care plan
    • relevant monitoring findings, treatment or episode of care, as well as the patient’s response to that care
    • facts relating to any patient accident or incident, including evidence of any injury, all parties notified, nursing care provided and patient’s condition after care is rendered
    • laboratory and diagnostic test results, especially those that are abnormal and require provider notification and/or intervention
    • referral and consultation requests and results
    • telephone, face-to-face and electronic contacts with other members of the healthcare team, including the content of discussions and agreed-upon follow-up.
  • Document discussions with the patient about 
  • Record medications administered, including injections, ointments and infusions, as well as a description of the patient’s response as Also record self- administered medications.
  • Detail nursing observations during patient
  • Specify patient’s questions and answers given regarding the nursing care/service plan, as well as the goals and methods of treatment.
  • Describe the patient’s response to nursing
  • Note the review of current problems and plan of
  • Assess skin and wound condition, including clinical findings and observations, and interventions, the nursing care/service plan and the patient’s response to treatment.
  • Document practitioner notification of a change in condition, symptoms, or patient concerns and document the practitioner’s response and/or orders, as well as any changes in the treatment plan
  • Summarize communications with practitioners, including those via telephone, facsimile and e-mail, text messages and patient portal communication and note any subsequent orders and nursing interventions.
  • Note use of an interpreter, including the interpreter’s contact information, as well as the patient or family member’s willingness to communicate with an interpreter.

Documentation – Medications and Prescriptions

  • Review and update the current medication list and patient’s reported adherence to prescribing orders. The list should include both prescribed and over-the-counter medications, including supplements and holistic/alternative remedies.
  • Collect and document the appropriate medication history as an essential component of the medication reconciliation process following patient admission, changes in care or treatment, transfer from one service to another (e.g., after surgery or delivery), or post-discharge return to
  • Clearly describe patient responses to medications, expected and unexpected.
  • Document signs or symptoms of adverse drug reactions, contact with physicians/licensed independent practitioners and subsequent follow-up. Based on facility policies and procedures, contact with the patient’s pharmacy as well as the facility’s pharmacy may be warranted.
  • In the case of any rare verbal orders, document that the order was read back and verified.

For additional information regarding medications and prescriptions, refer to the Nurse Spotlight: Medication Administration.

Documentation – Diagnostic Tests, Referrals, Consultations

  • Contact the patient’s healthcare provider to report abnormal test results and any provider orders for additional testing or follow-up and document the interaction.
  • In cases of a non-response/delay or urgent/emergent consultation, contact the consulting physician(s) or practitioner(s) to confirm that the consulting provider was notified of the consultation request and to facilitate the timely provision of the consultation and receipt of the results, as needed. Document these actions in the patient’s healthcare information record.
  • Utilize the chain of command to report abnormal laboratory results and the results of consultations if the ordering/primary care provider (physician, APRN, PA) is not available or does not respond to messages.
  • Initiate additional steps, if necessary, to ensure timely patient These may include escalating to the supervisor/ nurse manager, administrators, attending or covering physician, licensed independent practitioner and/or medical staff leadership until the abnormal result is addressed

Documentation – Patient Education

  • Describe patient and family healthcare education encounters, listing the presence of specific family members and their relationship to the patient.
  • Document an assessment of the patient’s ability to comprehend and repeat information provided using a “teach-back” approach, both immediately and after a few minutes have elapsed to test accurate recall.
  • Provide a written assessment of the patient’s appropriate demonstration of procedures/taught tasks, such as blood glucose testing or application of dressings.
  • Maintain a copy of written materials provided and document references to standard educational tools.
  • Retain patient-signed receipts for any educational materials If a family member or friend receives the education materials due to the patient’s cognitive abilities, reflect a note in the healthcare information record to that effect. The family member’s or friend’s name should be documented as the person that received the materials.
  • Document the use of interpreters, if needed, and include the interpreter’s contact information.
Article references 

 American Nurses Association (2015). Nursing Scope and Standards of Practice (3rd Ed.). Silver Spring, MD: ANA.

U.S. Department of Health and Human Services, Office of Inspector General. A Roadmap for New Physicians: Fraud and Abuse Laws. https://oig.hhs.gov/compliance/physician-education/01laws.asp.

NSO and CNA (2020). Nurse Professional Liability Exposure Claim Report (4th Ed.). www.nso.com/nurseclaimreport.

This information was excerpted from NSO and CNA’s full report, Nurse Professional Liability Exposure Claim Report: 4th Edition. www.nso.com/nurseclaimreport

Education
LSNA Trafficking Task Force

Louisiana State Nurses Association (LSNA), Nurses Against Trafficking Task Force (NATT), the National Coalition for the Prevention of Human Sex Trafficking (NCPHST), and a host of other state and local experts have partnered to develop the state's first standardized human trafficking training, specifically for the medical community.  The training includes best practice information for medical providers on how to identify and report human trafficking, along with a pre-test and post-test with answers.  

Register for Preparing Healthcare Providers to Respond to Human Trafficking Here

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