Medical documentation serves many purposes. It is used to record the course of patient evaluation, treatment, and response to treatment; facilitate the coordination of healthcare efforts; provides a means for continuity of care; document compliance with accreditation standards and regulatory agencies; provide an objective basis for insurance reimbursement; provide data for research and clinical trials; demonstrate that the patient and/or family members were kept informed about the patient's condition, care options, and ways in which the patient can maximize his or her outcome; and serve as a legal record of care to help reconstruct events and potentially defend healthcare providers/institutions if a claim arises (Carroll, 2004; Joseph & Webster, 2002).
The following "do's and don'ts" represent some of the more common issues in chart documentation:
* All entries must be legible. Illegible entries can prevent effective communication between caregivers and even contribute to medical errors. Sloppy handwriting can equate with sloppy care in the minds of jurors.
* Document objectively and truthfully without speculation, value judgments or personal opinions.
* Never use the chart to disagree with or berate another caregiver.
* Avoid words that convey an adverse occurrence such as "unintentionally," "inadvertently," "unexpectedly" and those that cast doubt such as "appeared," "apparently," and "seems to be."
* Documentation from sources other than direct observation must be indicated such as "The patient's husband stated that his wife exercised at the gym three days after surgery."
* Document in a timely manner to help ensure accuracy and enable other caregivers to base their interventions on complete medical information.
* All entries must be authenticated by the author, with an original signature containing full name and professional designation. This includes all office personnel.
* Entries must be in chronological order, avoiding gaps. Check your state regulations regarding late entries and how they should be documented.
* When you document, ensure that the chronology makes sense-patients can only be in one place at one time. In addition, you should be able to "locate" the patient at any given time during his or her perioperative stay at your facility and identify from the record who is responsible for care at that given moment.
* Never squeeze in entries to avoid the appearance of record tampering.
* Document the appropriate information on the appropriate form.
* Fill out forms completely. Use "N/A" in blanks that do not apply.
* Make sure forms are easy to read and not slanted, cut off at the sides, or too light.
* Make sure that the patient's name is at the top of every page.
* Ensure that important information is shared between healthcare providers. For example, when allergies are identified, use the system developed by the practice to ensure that all caregivers are warned (example: brightly colored allergy sticker on the front cover of the chart).
* Document in blue or black nonerasable ink. Never document in pencil or felt-tip marker or use any ink that fades or bleeds through the paper.
* Entries must include the current date, month, and year. Documentation on the day of surgery must be timed. Other documentation that occurs within a tight time frame should also be timed such as immediately before, during, and immediately after an adverse occurrence or when notifying another caregiver that a problem exists. Time should be recorded in either a.m./p.m. or military time on a consistent basis.
* Avoid using abbreviations whenever possible. If abbreviations are to be used, develop a list of facility-approved abbreviations and use only those.
* Once an entry is made, it must be left intact. Never use white-out; never erase, obliterate, or otherwise attempt to delete an entry, as this could lead to accusations of tampering and concealment.
* To correct an error in the medical record, a single line should be drawn through the entry, the error should be initialed and dated, and the correct information should be placed above the erroneous entry. If the corrected information cannot fit above the error, a corrected note should be placed in the same day's notes (dated and signed with the reason for the correction noted).
* Adverse incidents must be documented carefully using an objective description of the event. Include date and time; what was observed; assessments, interventions, and follow-up care relating to the event; and statements made by the patient/family and what was told to them and by whom. Incident reports that have been completed should never be alluded to in the patient's chart documentation.
* Corrections or additional entries after a serious adverse incident should be written very carefully (if at all) with the help of legal counsel, as they could negatively impact your defense in a legal proceeding. Do not speculate as to the cause of the adverse occurrence or assign blame in your notes.
* Document all patient teaching including preoperative, postoperative, and discharge instructions; who was present during the session; and the content of the session. Patient teaching is a nursing obligation, and while it is done routinely, it is not always noted in the record. Ascertain and document that the patient states that he or she understands what was taught. Document that patient was afforded the opportunity to ask questions and have them answered to his or her satisfaction.
* If an interpreter is required, try to use a healthcare translator or an approved healthcare translation service and document the use of this service. If family members or non- healthcare personnel serve as translators, document the patient's approval and who is fulfilling that role.
* It is extremely important to accurately document the patient's refusal or failure to comply with treatment recommendations.
* When patients do not present for appointments, document these patient "no-shows" and your attempts to contact the patient and reschedule the appointment.
* Document all significant telephone interaction including the time and date of the call, the content of the discussion, and any advice given and to whom it was given. Make sure those giving medical advice are licensed to do so. Telephone documentation should be filed chronologically in the chart.
* Once a problem has been identified and documented, do not stop there-identify what intervention was taken, who was notified, and that the problem was resolved appropriately.
* If patients were seen or contact was made between patients and the staff over the weekend or during a holiday, document those encounters as soon as possible or the next business day.
* Do not forget to address the psychosocial needs of the patient in your care and documentation.
* Document that the patient/ family were kept informed of the patient's condition, treatment, progress, and self-care recommendations.
* Do not perform "documentation favors" by completing another's notes, correcting another's notes, destroying another's notes, or signing off on another healthcare practitioner's interventions.
* Verbal orders should be cosigned by the healthcare professional giving the order and accepted only by those authorized to take such orders.
Long after memories fade, the well-documented medical record will be there to support the healthcare provider, should the need arise. Keep in mind that "if it wasn't documented then it wasn't done[horizontal ellipsis]," and when you make a chart entry, read your note through the eyes of a jury member. Does it make sense, contain all of the relevant information in the appropriate chronology, and does it convey that you are a thorough, thoughtful, and professional caregiver?
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