1 Documentation in the Medical Record

2 Objectives  To illustrate the importance of appropriate documentation in the medical record  To review basic principles of appropriate documentation  To identify common documentation errors

3  Allegation: Staff did not properly diagnose or treat shock.  Injury: Death  Evidence: Resident physicians state they were in the patient’s room within 10 minutes of being notified of change in status by nurse and provided appropriate care. Case #1

4  Evidence: There was no documentation that a physician was present until 90 minutes after being called, nor was there documentation of the care provided to the patient.  Disposition: Department of Health citation Case #1 (cont’d)

5  Allegation: Staff did not properly diagnose or treat hypoglycemia.  Injury: Blindness, developmental delay  Evidence: Parents testified that the infant was not brought to the mother for regular feedings. There was no documentation of feeding times in the chart. It appeared as if the infant was not fed for 12 hours.  Disposition: Case settled out of court. Case #2

6 Case #3  Allegation: Staff failed to prevent decubitus ulcers in a teenaged patient receiving epidural pain medication following a urological procedure.  Injury: Stage decubitus ulcer on the left heel requiring skin grafting. Stage 1 decubitus ulcer on the left knee.

7 Case #3 (cont’d)  Evidence: There was no documentation that the patient was repositioned every 2 hours as required by the hospital epidural policy. After the decubitus ulcer was identified, there was no documentation that the patient was reassessed or repositioned.  Disposition: Case settled out of court.

8 Case #4  Allegation: Staff failed to recognize and address deterioration of a patient’s neurological status, and failed to correctly diagnose a spinal fracture.  Injury: Paraplegia  Evidence: Poor documentation created an unclear picture as to when the patient’s neurological deficits were first noted.

9 Case #4 (cont’d)  Evidence:  There was no documentation of an initial physical assessment.  Documentation stated that the patient had “no response” to lower extremity movement for 2 hours with no intervention.

10 Case #4 (cont’d)  Evidence:  Skin exam documented as “c” for “cold”.  The “c” appears to have been written over a “w” for “warm”.  This calls into question the integrity of other chart entries.  It also appeared that this may have been charted to agree with the resident physician’s note that the skin was cold.

11 Case #4 (cont’d)  Evidence:  Notes were timed, but not in sequence:  7:00 pm: Minimal movement of toes.  Next entry, timed as 6:40 pm: Patient unable to wiggle toes, did not respond to touch on bottom of feet, legs were floppy. Patient could not initiate any movement.  7:30 pm: Physician in to assess patient.  Disposition: Case settled out of court.

12 Purpose of the Medical Record  Communication among caregivers about patient’s condition, care and response to treatment  Evidence in legal proceedings  Reimbursement  Data for research studies  Planning and implementing quality improvement measures

13 Legal Considerations  Be clear and specific so that information is unambiguous to any other healthcare provider, or a jury.  You will not remember the occurrence in vivid detail five years later!

14 Legal Considerations  Falsifying or altering a medical record is professional misconduct reportable to the Office of the Professions. It is also a misdemeanor in some states.  Never document events in advance.

15 Legal Considerations  What catches an attorney’s eye?  Pages without patient identification  Dates and times that do not correlate with the remainder of the chart  Changes in slant, uniformity, or pressure of handwriting

16 Legal Considerations  What catches an attorney’s eye?  Changes in ink or pen on the same entry  Erasures or obliterations  Entries written over previous entries to correct or change them

17 Common Documentation Errors  Omissions  Include all facts needed to provide care to the patient. If you did not document it, you did not do it!

18 Common Documentation Errors  Personal Opinions  Record only factual and objective observations.  Vague Entries  Instead of documenting “Patient had a good day”, state why: “Patient denied having pain.”

19 Common Documentation Errors  Late Entries  Identify documentation as a Late Entry.  Record the date and time of the Late Entry and the date and time to which you are referring (04/01/07 at 9:00 am for 3/31/07 at 11:30 pm).

20 Common Documentation Errors  Improper Corrections  A single line should be drawn through erroneous information.  The individual making the correction should sign, date and time the correction.  Do not use correcting fluid.  Do not obliterate the original entry.

21 Common Documentation Errors  Unauthorized Entries  Do not document for anyone else.  Illegibility and lack of clarity  Document so others can read and understand your entry. Use correct spelling.

22 Common Documentation Errors  Unsafe Abbreviations  Avoidance of unsafe abbreviations is mandated by the Joint Commission.  Do not abbreviate medication names.  See next slide.

23 Unsafe Abbreviations Unsafe abbreviations DO NOT USE Appropriate documentation USE AD, AS, AURight ear, left ear, both ears BIW, TIWTwo times per week, three times per week IUInternational units OD, OS, OURight eye, left eye, both eyes QD, QODDaily, every other day x3dFor 3 doses or for 3 days UUnits UgMcg

24 Date and Time  All entries in the medical record must include a date and time.  This is a Centers for Medicare and Medicaid regulation. Take the time To date and time!

25 Pain Documentation  Assess pain as the fifth vital sign  Include: OnsetCharacteristic LocationAggravating factors DurationRelieving factors Temporal factors Severity  Use approved pain scale  e.g. CRIES, FACES, Numeric, PAINAD

26 Key Points  Documentation in the medical record must be clear, accurate and thorough.  Appropriate documentation promotes quality patient care by improving communication between healthcare providers and reducing the risk of medical errors.