Date post: | 15-Dec-2015 |
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Goals and Objectives
Identify Sound Documentation Practices
Discuss Medical Record Documentation Standards
Review Patient Information Confidentiality Issues
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
Best Defense Against a Malpractice Claim
Good Medical Record Completeness Objectivity Consistency Accuracy
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
Common Allegations Against Nurses
Failure to: Interpret & Follow Physician Orders Report Questionable Care Report Substandard Medical Practices Monitor Implement Safety Measures DOCUMENT CARE
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
What Do Plaintiff's Attorneys Look For?(cont.)
Illegibility of Entries By Anyone
Extraneous Remarks Feuding Among
Professionals
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
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
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.
Documenting Patient Injuries
IF YOU FAIL TO DOCUMENT THE OCCURRENCE (I.E., FALL FROM BED), THE ALLEGATION OF COVER-UP MAY BE EASILY SUSTAINED.
Documenting Occurrences
Document Only What You See Record Vital Signs Physical Condition Mental Condition Subjective Complaints Physician Notification Treatments Ordered
Sign Your Notes!
Sign Every Entry Never Sign Someone Else’s Notes Countersigning (Only As Verification)
How to Correct a Medical Record
Single Line Through Inaccurate Material
Date & Initial Add Note Re: Correction Enter Correction (Chronological
Order)
Legible Charting
Single Most Effective Way to Improve Medical Records!
Writing Legible Requires No Additional Time
When Defending Malpractice Actions, Illegible Record No Help
Select Your Words
Avoid“Unintentionally”“Inadvertently”“Somehow”“Unexplainably”“Unfortunately”“Apparently”
Objective vs. Subjective
Charting Must Be Objective & Void of Conclusions
State Specifically What You: See Hear Smell Feel
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!
Use of Abbreviations
Use Only Formally Authorized
No Abbreviations for Dx (Diagnosis), Surgical Procedures or Medications
Submit New Abbreviations Watch for Dual Meanings
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
Documentation
“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 such