Chapter 8 DOCUMENTATION
Importance of Documentation Provides for the following: A written record of the incident A legal record of the incident Professionalism Medical audit Quality improvement Billing and administration Data collection
Why to keep records? Legal obligation Helps in medical decisions Helps to share responsibility with the patient All reputed Hospitals Keep Your Documents for several decades. Legal obligation Protects the patient as well as doctor in front of the court
Legal Aspects of Charting Be accurate about time & chart as soon as possible after an event Document omissions (med not given or treatment not completed) & reason & actions taken Do not leave blank spaces Record legibly & in black ballpoint pen
Legal Aspects of Charting Do not erase, use white-out, or scribble out errors Do not write retaliatory or critical comments; do not place blame on your colleagues Correct all errors promptly Spell correctly Record all facts in objective terms
Court Believes your Documents only Document completely (in court - if it's not documented, it wasn't done)
Correct your Mistakes with Sense and Legality Never use whitener Never scratch out Draw a line through the mistake Initial above the mistake
Rules in keeping medical records as it requires Confidentiality Personal biographical data include the address, employer, home and work telephone numbers and marital status. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. All entries are dated.
Rules..Contd... The record is legible to someone other than the writer. 4. Significant illnesses and medical conditions are indicated on the problem list. 5. Medication allergies and adverse reactions are prominently noted in the record.
Types of Medical Records
Elements of Good Documentation Accuracy Legibility Timeliness Unaltered Professionalism Completeness
Professionalism Never include slang, biased statements, or irrelevant opinions. Include only objective information. Always write and speak clearly.
Narrative Writing Subjective part of your narrative comprises any information you elicit during your patient’s history. Objective part of your narrative usually includes your general impression and any data you derive through inspection, palpation, auscultation, percussion, and diagnostic testing.
Two Narrative Formats CHART SOAP Chief complaint Subjective History Assessment Rx (treatment) Transport SOAP Subjective Objective Assessment Plan
Triage tags are used to record vital information on each patient quickly.
Medical Billing and Coding Needs Documentation Without adequate medical documentation, your health care providers might not be reimbursed for providing you with care, leaving you stuck with the bill. There's an old saying in the health care industry: "If it's not documented, it didn't happen.
Consequences of Inappropriate Documentation Inappropriate documentation can have both medical and legal consequences. Do not guess about your patient’s problems. Write neatly, clearly, and legibly. Complete your form completely. Spelling counts!
Excellence in Medical Documentation Reduces Malpractice Allegations Excellence in medical documentation reflects and creates excellence in medical care. At its best, the medical record forms a clear and complete plan that legibly communicates pertinent information, credits competent care. Forms a tight defense against allegations of malpractice by aligning patient and provider expectations.