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Documentation & Risk Management Issues. Goals and Objectives  Identify Sound Documentation Practices  Discuss Medical Record Documentation Standards.

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Presentation on theme: "Documentation & Risk Management Issues. Goals and Objectives  Identify Sound Documentation Practices  Discuss Medical Record Documentation Standards."— Presentation transcript:

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 Select Your Words  Avoid “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 z“If you didn’t write it, you didn’t do it”! zRules for documentation in the medical record: êWrite legibly êDo not leave blank lines êAll people giving care must be identified êDraw a line through errors and initial êDocument in chronological order êVerbal orders must be signed off by MD êLate entries must be noted as such

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


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