1. Chapter 8
DOCUMENTATION

2. Importance of Documentation
Provides for the following:
A written record of the incident
A legal record of the incident
Professionalism
Medical audit
Quality improvement
Billing and administration
Data collection

3. Why to keep records? Legal obligation Helps in medical decisions
Helps to share responsibility with the patient
All reputed Hospitals Keep Your Documents for several decades.
Legal obligation
Protects the patient as well as doctor in front of the court

4. Legal Aspects of Charting
Be accurate about time & chart as soon as possible after an event
Document omissions (med not given or treatment not completed) & reason & actions taken
Do not leave blank spaces
Record legibly & in black ballpoint pen

5. Legal Aspects of Charting
Do not erase, use white-out, or scribble out errors
Do not write retaliatory or critical comments; do not place blame on your colleagues
Correct all errors promptly
Spell correctly
Record all facts in objective terms

6. Court Believes your Documents only
Document completely (in court - if it's not documented, it wasn't done)

7. Correct your Mistakes with Sense and Legality
Never use whitener
Never scratch out
Draw a line through the mistake
Initial above the mistake

8. Rules in keeping medical records as it requires Confidentiality
Personal biographical data include the address, employer, home and work telephone numbers and marital status.
All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials.
All entries are dated.

9. Rules..Contd...
The record is legible to someone other than the writer.
4. Significant illnesses and medical conditions are indicated on the problem list.
5. Medication allergies and adverse reactions are prominently noted in the record.

10. Types of Medical Records

11. Elements of Good Documentation
Accuracy
Legibility
Timeliness
Unaltered
Professionalism
Completeness

12. Professionalism
Never include slang, biased statements, or irrelevant opinions.
Include only objective information.
Always write and speak clearly.

13. Narrative Writing
Subjective part of your narrative comprises any information you elicit during your patient’s history.
Objective part of your narrative usually includes your general impression and any data you derive through inspection, palpation, auscultation, percussion, and diagnostic testing.

14. Two Narrative Formats CHART SOAP Chief complaint Subjective History
Assessment
Rx (treatment)
Transport
SOAP
Subjective
Objective
Assessment
Plan

15. Triage tags are used to record vital information on each patient quickly.

16. Medical Billing and Coding Needs Documentation
Without adequate medical documentation, your health care providers might not be reimbursed for providing you with care, leaving you stuck with the bill.
There's an old saying in the health care industry: "If it's not documented, it didn't happen.

17. Consequences of Inappropriate Documentation
Inappropriate documentation can have both medical
and legal consequences.
Do not guess about your patient’s problems.
Write neatly, clearly, and legibly.
Complete your form completely.
Spelling counts!

18. Excellence in Medical Documentation Reduces Malpractice Allegations
Excellence in medical documentation reflects and creates excellence in medical care.
At its best, the medical record forms a clear and complete plan that legibly communicates pertinent information, credits competent care.
Forms a tight defense against allegations of malpractice by aligning patient and provider expectations.