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

Select Your Words

Avoid“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 legiblyDo not leave blank linesAll people giving care must be identifiedDraw a line through errors and initialDocument in chronological orderVerbal orders must be signed off by MDLate entries must be noted as such

In Summary

REMEMBER

POOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!!