Documentation by qingyunliuliu

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									Documentation
&
Risk Management Issues
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.
Physician Notification

Always Note:
 Time MD Notified Changed Condition
 Medical Facts Relayed
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)
Protect Yourself

   Never Alter Medical Records
   Never Skip Lines
   Never Obliterate
   Document with Ink
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 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
In Summary

          REMEMBER

 POOR DOCUMENTATION CAN MAKE
     GOOD CARE LOOK BAD!!!!

								
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