Documentation & Risk Management Issues

Goals and Objectives Identify Sound Documentation Practices Discuss Medical Record Documentation Standards Review Patient Information Confidentiality Issues

Importance of the Medical Record in Risk Management Best Defense Against Lawsuit Provides Evidence of Interventions & Interactions Made in the Regular Course of Business Source of Information for Risk Identification & Quality Improvement

Best Defense Against a Malpractice Claim Good Medical Record Completeness Objectivity Consistency Accuracy

Purpose of the Medical Record Communication Tool Between Clinicians Assists with Obtaining Reimbursement Continuity (Evaluation Patient’s Condition) Documentary Evidence (Evaluation, Treatment, & Change in Condition) A “Very Public” Document

Common Allegations Against Nurses Failure to: Interpret & Follow Physician Orders Report Questionable Care Report Substandard Medical Practices Monitor Implement Safety Measures DOCUMENT CARE

What Do Plaintiff’s Attorneys Look For? Omissions Contradictions & Inconsistencies Time Delays & Unexpected Time Gaps Alterations or “Appearance of” Lack of Supervision Lack of Informed Consent Lack of Patient Education Information

What Do Plaintiff's Attorneys Look For?(cont.) Illegibility of Entries By Anyone Extraneous Remarks Feuding Among Professionals

Benefits of “Quality Documentation” Plaintiff's Attorney May Not Take Case Early Settlement More Reliable Than Personal Recollection Refresh Memory Demonstrates Good Communication Demonstrates Quality Medical Care

What Is Good Documentation? Timely, Accurate, & Comprehensive Numbers and measurements are actual figures vs. “small” or “many” Quotation marks are used when reporting patient’s statements Contains only facts, not opinions or guesses Spelled correctly and written with approved abbreviations and correct medical terminology Clear and concise

What Is Good Documentation? Dated, Legible, and Signed using blue or black ink Reflects Decision-Making Process and Patients’ reaction to the procedure. Each Form Is Completed Entirely – no blanks Identified with patient’s name.

Physician Notification Always Note: Time MD Notified Changed Condition Medical Facts Relayed

Documenting Patient Injuries IF YOU FAIL TO DOCUMENT THE OCCURRENCE (I.E., FALL FROM BED), THE ALLEGATION OF COVER-UP MAY BE EASILY SUSTAINED.

Documenting Occurrences Document Only What You See Record Vital Signs Physical Condition Mental Condition Subjective Complaints Physician Notification Treatments Ordered

Sign Your Notes! Sign Every Entry Never Sign Someone Else’s Notes Countersigning (Only As Verification)

Protect Yourself Never Alter Medical Records Never Skip Lines Never Obliterate Document with Ink

How to Correct a Medical Record Single Line Through Inaccurate Material Date & Initial Add Note Re: Correction Enter Correction (Chronological Order)

Legible Charting Single Most Effective Way to Improve Medical Records! Writing Legible Requires No Additional Time When Defending Malpractice Actions, Illegible Record No Help

Avoid Select Your Words “Unintentionally” “Inadvertently” “Somehow” “Unexplainably” “Unfortunately” “Apparently”

Objective vs. Subjective Charting Must Be Objective & Void of Conclusions State Specifically What You: See Hear Smell Feel

Objective vs. Subjective (cont.) Checked on rounds q 2 hours, eyes closed, respiration's regular vs. Slept all night Taking medications as prescribed vs Quiet and cooperative. No c/o pain or discomfort vs. Had a good day!

Use of Abbreviations Use Only Formally Authorized No Abbreviations for Dx (Diagnosis), Surgical Procedures or Medications Submit New Abbreviations Watch for Dual Meanings

Medical Records & Confidentiality & Security Maintain Physical Security Never Remove Records from the Facility Release Records Only Through P&P No Unauthorized Copying of Records No Access to Records By Unauthorized Individuals

Documentation “If you didn’t write it, you didn’t do it”! Rules for documentation in the medical record: Write legibly Do not leave blank lines All people giving care must be identified Draw a line through errors and initial Document in chronological order Verbal orders must be signed off by MD Late entries must be noted as such Some of the most common incidences of liability for the HC worker result from inadequate charting. Remember when documenting: Be legible Be descriptive – describe what was observed and what was done Be objective – don’t state your opinion Pt appears restless vs. Pt thrashing side to side in bed Pt’s appetite is good vs “pt ate ½ of lunch” Be succinct and timely – Documentation should be placed where it logically belongs. Be careful – if mistake is made follow agency’s policy – never erase, discard, or white-out – fraudulently altering a chart or falsifiing the record is a crime.

POOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!! In Summary REMEMBER POOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!!