LNCtips.com: "Will Continue to Monitor"
"Will continue to monitor." Those four words make defense lawyers cringe and plaintiff attorneys cheer. Why? Because inevitably, some nurses who write those words document the decline of a patient's condition without doing anything about it. Here's why I think this happens and what nurses and legal nurse consultants should consider.
I think nurses ignore changes in patients' condition when their conditions decline gradually. For example, when I was a surgical ICU nurse, I went on walking rounds one morning with another nurse at the change of shift to get report. I noticed that one patient had a droopy right eye, droopy right side of his mouth, a weak right upper extremity, and a flaccid right lower extremity. He hadn't shown any of those signs the day before. After the nurse gave her report about this patient, I asked her, "When did he have a stroke?" She said, "Stroke? What stroke?" The nurse had dutifully charted her assessments of the patient all shift. However, even though she assessed the patient every hour, she failed to notice that there were subtle changes in the patient's condition each hour. By the time her shift was over, the overall changes were dramatic and devastating for the patient.
Therein lies a problem with the sentence, "Will continue to monitor." This sentence makes it appear as if the nurse is monitoring the patient but not truly thinking about the patient's condition and connecting the dots. When a nurse writes "Will continue to monitor" without notifying the physician or other provider of significant condition changes, the nurse is a target for lawsuits, often rightfully so. Unfortunately for patients, significant condition changes can occur over time as happened with the stroke patient.
Another problem with, "Will continue to monitor" is that it's a meaningless filler sentence - there's no need for it. In my opinion, "Will continue to monitor" is worthless documentation. Monitoring is as much a part of nurses' responsibilities as other responsibilities, such as administering meds or changing dressings. Nurses don't write, "Will continue to administer medications" or, "Will continue to change the patient's dressing."
A final problem with, "Will continue to monitor" occurs when there's no documentation supporting that the nurse DID continue to monitor. I recently reviewed a case involving a patient's slowly developing paralysis after an accident. The nurse assessed the patient at the start of the shift, and documented that the patient complained of numb legs. The nurse wrote, "Will continue to monitor," but she never assessed the patient again on her twelve hour shift. By the time the next nurse assessed the patient at the start of the shift, the patient was paraplegic.
What should nurses do instead of writing, "Will continue to monitor?" Rather than taking 10 seconds to type that sentence, nurses should take 10 seconds to ask themselves one or two questions. The first one is, "Has this patient's condition changed since the last shift? If the answer to that question is "no", the second question is irrelevant. If the answer to the first question is "yes", nurses should ask the second question "Is this change significant?" If yes, nurses need to notify the patient's provider. If my co-worker had asked herself these questions each time after she assessed the stroke patient, his outcome might have been different.
Just as I had the benefit of being able to identify a stroke because it was full-blown by the time I saw it, LNCs who review medical records have the benefit of knowing the allegations ahead of time. It's quite easy to point to the end result and say, "Aha! The nurse should have done something about this!" LNCs should really review medical records with the same two questions in mind. Had the patient's condition changed since the last shift? If so, was the patient's provider notified? Of course, if the nurse never performed another assessment when an assessment was indicated, it's probably a breach in the standard of care.
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