1. Documentation & Risk Management Issues

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

3. 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

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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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.

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

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

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

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

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

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

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

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

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

21. 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!

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

23. 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

24. 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.

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