The Medical record

1. This Power Point is an “Interactive Review” of Chapter 26 material The Medical record

2. Defining the Medical Record • Legal document • Communication vehicle between healthcare providers • Implementing quality improvement • Utilization review for reimbursement • Research/education • Most credible evidence in legal proceedings on whether the care given to the patient met the legal standard of care

3. Avoid Documentation Pitfalls • Be objective • Examples? • Write legibly • Document at the same time as your assessment and/or treatment • Avoid gaps in the medical record • Follow the facility’s documentation policies • Document adverse events properly

4. Waving RED FLAGS An attorney in a professional negligence case will examine the medical record for evidence that will help prove the case, such as:

5. Waving RED FLAGS • Notes that are sloppy, incomplete, illegible, or have gaps. These reflect poorly on the nurse and undermine the nurse’s credibility in front of a jury • Entries that aren’t times or dated or that appear out of sequence

6. Waving RED FLAGS • Entries that indicate delays or failures in initiating treatment orders • Entries that show the care provided was substandard or inappropriate

7. Waving RED FLAGS • Entries that show care rendered that wasn’t supported by a healthcare provider’s prescription • Unexplained late entries • Erased or obliterated entries

8. Waving RED FLAGS • Lack of documentation of patient education or discharge instructions • Entries made with different ink or pen (if the record is handwritten) • The statement “completed an event report,” which can serve as a red flag that something went wrong during the patient’s care

9. Review of Chapter 26

10. One of the primary functions of medical records is to serve as the main source of information regarding the pt’s ____________ & ___________. Treatment & Progress

11. True or False? Healthcare records can be seen and used by non- healthcare personnel who have proper authority. True. This includes state licensing boards, attorneys with authorization, and insurance companies.

12. Two entities that regulate the contents of medical records are: CMS (Centers for Medicare and Medicaid Services) & Joint Commission

13. A _________ ________ gives a detailed and accurate description of the pt’s condition, nursing assessment & interventions, and outcomes. Complete Record

14. During legal proceedings, the medical record is often called the “witness that never dies.” True. Therefore complete and timely documentation works in the nurse’s favor.

15. A nurse’s note is never complete without documentation of the _____ & ____ the note was written. Date & Time

16. It is acceptable for the nurse to place initials on a data flow sheet even it the flow sheet does not contain the nurse’s full name and title anywhere on the page. False. The nurse’s full name/title must appear somewhere on the sheet to coincide with the initials.

17. The patient’s name must at least appear on every other page of the medical record. False. The patient’s name must appear on every page of the medical record.

18. Sloppy records often equate with sloppy nursing care. True. If a nurse’s note is difficult to read or understand, then it fails to meet the standard.

19. Whenever possible, the nurse should use __________ terms in documentation (e.g. “2 cm wide”) measurable

20. The only subjective data in a nurse’s note should be the patient’s own statements placed in quotes. True.

21. Health care providers must document using only _________- approved medical abbreviations. hospital

22. Corrections to mistakes in documentation should be made according to: • Joint Commission • Facility/agency policy • ANA • CMS

23. Writing subjective comments about co-workers in a pt’s medical record is acceptable so long as it pertains to on- the-job activities. False. Problems with co-workers should be addressed through other more appropriate channels.

24. What is one negative aspect of “charting by exception”? It may be a less accurate and less detailed account of a pt’s course of Tx.

25. CMS requires medical records to be retained or reproduced for ___ years. • 7 • 4 • 5 • 10