2Goals and Objectives Identify Sound Documentation Practices Discuss Medical Record Documentation StandardsReview Patient Information Confidentiality Issues
3Importance of the Medical Record in Risk Management Best Defense Against LawsuitProvides Evidence of Interventions & InteractionsMade in the Regular Course of BusinessSource of Information for Risk Identification & Quality Improvement
4Best Defense Against a Malpractice Claim Good Medical RecordCompletenessObjectivityConsistencyAccuracy
5Purpose of the Medical Record Communication Tool Between CliniciansAssists with Obtaining ReimbursementContinuity (Evaluation Patient’s Condition)Documentary Evidence (Evaluation, Treatment, & Change in Condition)A “Very Public” Document
6Common Allegations Against Nurses Failure to:Interpret & Follow Physician OrdersReport Questionable CareReport Substandard Medical PracticesMonitorImplement Safety MeasuresDOCUMENT CARE
7What Do Plaintiff’s Attorneys Look For? OmissionsContradictions & InconsistenciesTime Delays & Unexpected Time GapsAlterations or “Appearance of”Lack of SupervisionLack of Informed ConsentLack of Patient Education Information
8What Do Plaintiff's Attorneys Look For?(cont.) Illegibility of Entries By AnyoneExtraneous RemarksFeuding Among Professionals
9Benefits of “Quality Documentation” Plaintiff's Attorney May Not Take CaseEarly SettlementMore Reliable Than Personal RecollectionRefresh MemoryDemonstrates Good CommunicationDemonstrates Quality Medical Care
10What Is Good Documentation? Timely, Accurate, & ComprehensiveNumbers and measurements are actual figures vs. “small” or “many”Quotation marks are used when reporting patient’s statementsContains only facts, not opinions or guessesSpelled correctly and written with approved abbreviations and correct medical terminologyClear and concise
11What Is Good Documentation? Dated, Legible, and Signed using blue or black inkReflects Decision-Making Process and Patients’ reaction to the procedure.Each Form Is Completed Entirely – no blanksIdentified with patient’s name.
13Documenting Patient Injuries IF YOU FAIL TO DOCUMENT THE OCCURRENCE (I.E., FALL FROM BED), THE ALLEGATION OF COVER-UP MAY BE EASILY SUSTAINED.
14Documenting Occurrences Document Only What You SeeRecord Vital SignsPhysical ConditionMental ConditionSubjective ComplaintsPhysician NotificationTreatments Ordered
15Sign Your Notes! Sign Every Entry Never Sign Someone Else’s Notes Countersigning (Only As Verification)
16Protect Yourself Never Alter Medical Records Never Skip Lines Never ObliterateDocument with Ink
17How to Correct a Medical Record Single Line Through Inaccurate MaterialDate & InitialAdd Note Re: CorrectionEnter Correction (Chronological Order)
18Legible Charting Single Most Effective Way to Improve Medical Records! Writing Legible Requires No Additional TimeWhen Defending Malpractice Actions, Illegible Record No Help
19Avoid Select Your Words “Unintentionally” “Inadvertently” “Somehow” “Unexplainably”“Unfortunately”“Apparently”
20Objective vs. Subjective Charting Must Be Objective & Void of ConclusionsState Specifically What You:SeeHearSmellFeel
21Objective vs. Subjective (cont.) Checked on rounds q 2 hours, eyes closed, respiration's regular vs. Slept all nightTaking medications as prescribed vs Quiet and cooperative.No c/o pain or discomfort vs. Had a good day!
22Use of Abbreviations Use Only Formally Authorized No Abbreviations for Dx (Diagnosis), Surgical Procedures or MedicationsSubmit New AbbreviationsWatch for Dual Meanings
23Medical Records & Confidentiality & Security Maintain Physical SecurityNever Remove Records from the FacilityRelease Records Only Through P&PNo Unauthorized Copying of RecordsNo Access to Records By Unauthorized Individuals
24Documentation “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 suchSome of the most common incidences of liability for the HC worker result from inadequate charting.Remember when documenting:Be legibleBe descriptive – describe what was observed and what was doneBe objective – don’t state your opinionPt appears restless vs. Pt thrashing side to side in bedPt’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.
25POOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!! In SummaryREMEMBERPOOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!!