Documentation & Risk Management Issues

1. Documentation&Risk Management Issues

2. Goals and Objectives • Identify Sound Documentation Practices • Discuss Medical Record Documentation Standards • Review Patient Information Confidentiality Issues

3. 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

4. Best Defense Against a Malpractice Claim • Good Medical Record • Completeness • Objectivity • Consistency • Accuracy

5. 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

6. Common Allegations Against Nurses Failure to: • Interpret & Follow Physician Orders • Report Questionable Care • Report Substandard Medical Practices • Monitor • Implement Safety Measures • DOCUMENT CARE

7. 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

8. What Do Plaintiff's Attorneys Look For?(cont.) • Illegibility of Entries By Anyone • Extraneous Remarks • Feuding Among Professionals

9. 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

10. 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

11. 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.

12. Physician Notification Always Note: • Time MD Notified Changed Condition • Medical Facts Relayed

13. Documenting Patient Injuries • IF YOU FAIL TO DOCUMENT THE OCCURRENCE (I.E., FALL FROM BED), THE ALLEGATION OF COVER-UP MAY BE EASILY SUSTAINED.

14. Documenting Occurrences • Document Only What You See • Record Vital Signs • Physical Condition • Mental Condition • Subjective Complaints • Physician Notification • Treatments Ordered

15. Sign Your Notes! • Sign Every Entry • Never Sign Someone Else’s Notes • Countersigning (Only As Verification)

16. Protect Yourself • Never Alter Medical Records • Never Skip Lines • Never Obliterate • Document with Ink

17. How to Correct a Medical Record • Single Line Through Inaccurate Material • Date & Initial • Add Note Re: Correction • Enter Correction (Chronological Order)

18. Legible Charting • Single Most Effective Way to Improve Medical Records! • Writing Legible Requires No Additional Time • When Defending Malpractice Actions, Illegible Record No Help

19. Select Your Words • Avoid “Unintentionally” “Inadvertently” “Somehow” “Unexplainably” “Unfortunately” “Apparently”

20. Objective vs. Subjective • Charting Must Be Objective & Void of Conclusions • State Specifically What You: • See • Hear • Smell • Feel

21. 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!

22. Use of Abbreviations • Use Only Formally Authorized • No Abbreviations for Dx (Diagnosis), Surgical Procedures or Medications • Submit New Abbreviations • Watch for Dual Meanings

23. 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

24. Documentation • “If you didn’t write it, you didn’t do it”! • Rules for documentation in the medical record: • Write legibly • Do not leave blank lines • All people giving care must be identified • Draw a line through errors and initial • Document in chronological order • Verbal orders must be signed off by MD • Late entries must be noted as such

25. In Summary REMEMBER POOR DOCUMENTATION CAN MAKE GOOD CARE LOOK BAD!!!!