Download LAW OFFICES OF BARBARA A. WEINER 600 Central Avenue Suite

LAW OFFICES OF
BARBARA A. WEINER
600 Central Avenue
Suite 325
Highland Park, Il 60035
847-266-2040
[email protected]
PROPER CLINICAL DOCUMENTATION
TO AVOID LIABILITY*
Good documentation protects the patient and the organization.
I. Why is documentation important?
Clinical Care: This is how the care team communicates with each other and
shows the patient’s condition and progress or lack of it.
Reimbursement: It shows the services that were provided and provides the
justification for payment.
Legal Protection: The patient’s record never lies and never dies. The
record will form the basis for defending your organization in a malpractice action.
Other Record Uses:
Coordination of care.
Measuring quality of care.
Measuring performance improvement of staff.
Documenting meeting standards for licensure and accreditation.
II. Clinical Documentation
a. Be objective and professional in all documentation.
b. Reflect individualized care that you provided. Do not depend on generic or
computer generated documentation that may be inaccurate.
c. Use correct spelling and grammar and do not use abbreviations that are not
authorized by your institution.
d. Complete all blanks or fields in the EHR-otherwise it may lead to a conclusion
that an issue was not addressed.
e. Document in a timely manner, after the care was provided.
f. Authenticate, date and time your entries.
______________________________________________________________________
*Copyright 2014. All rights reserved to Barbara A. Weiner
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g. Use an acceptable signature format.
h. For any prefilled entries in the EHR, be sure they are accurate.
i. If you are still using a written record, make sure your handwriting is legible.
j. Make sure you document the good and bad signs and symptoms to show the
ups and downs in the course of the patient’s stay. For example: “Patient states: ‘I have
a terrible headache’ or ‘I am feeling really good today’.
k. Complete all checklists and charts, they are equally as important as progress
notes.
III. Reimbursement. The key is that all services provided are properly documented.
For behavioral health therapy the time spent in the appointment also needs to be
documented. The key is that the organization is only billing for services provided and
not “up coding” by indicating a more costly service that was not provided.
IV. Legal Perspective Overview
A. Malpractice- is negligence in the performance of professional duties. There are
four elements:
1. Duty
2. Breach of Duty
3. Harm caused as a result of the breach of duty
4. Damages
B. The Role of the Record in the Attorney’s Analysis
1. Does the record document good or poor care?
2. Are there discrepancies in the record?
3. Are there negative statements about any providers?
4. Does it look like the record has been changed?
5. What isn’t documented?
The documentation will often be the critical factor in whether the attorney files a lawsuit.
The quality of the documentation will tell the jury the quality of patient care received.
Objective, timely, and complete documentation is the institution’s best defense.
C. Medical Studies Act/Peer Review Committee
1. The Medical Studies Act permits review of records for internal quality control
or for the purposes of reducing morbidity and mortality and improving patient care.
2. Peer review is done by a committee of peers (physicians evaluating
physicians or nurses evaluating nurses).
3. Any report generated must be for peer review purposes and not risk
management.
4. If it can be established that report relates to a peer review committee, the
records and notes are not discoverable.
The medical record is a witness that never lies and never dies.
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If it is not in writing it did not occur.
V. Nursing Documentation
1. Thorough physical, mental and social assessment.
2. Show patient’s condition and reflect the patient’s status.
3. Document any changes in condition including nursing care plan and
interventions. Include contact with the patient’s medical provider.
4. Show response to treatment or medications.
5. Document lack of improvement.
6. Family or significant others involvement as appropriate.
7. Patient/family education.
8. Statements of concern made by patient and/or family or significant others.
The nurse needs to be communicating to the treatment team every element that is
essential for the other health care providers to know so appropriate care is given.
VI. Documentation of Behavioral Health Issues. It is critical to document unusual
client sessions and what actions you took.
A. Threats of suicide.
1. Does the person have a specific plan?
2. Does the client have a weapon?
3. Did you move for civil commitment? If not, why not?
4. Is there a treatment contract?
5. What action have you taken and why?
B. Threats of harming others.
1. What is the threat and who is it against?
2. Do you view it as a meaningful threat or just the person letting off steam?
3. Does the client have the ability to carry out their plan? For example is the
person they are angry at nearby?
4. Do they have a weapon?
5. What action have you taken and why?
C. Client not following treatment plan.
1. Did you document what they are not following?
2. If they are not taking their medications have you asked why and considered side
effects?
3. If they are not keeping appointments have you done a wellness check? Have
you considered terminating care?
4. What action have you taken and why?
VII. Adverse Events. This is when something unexpected happens. It must be
documented correctly in the chart.
a. Give the pertinent clinical information including the event, date, time, and
place.
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b. Do not place blame on anyone.
c. Just be factual. Do not state an error.
d. List the patient’s condition immediately before the time of the event.
e. Notification of the physician.
f. Document the medical information following the event and the patient’s
response.
g. Do not refer to consultation with risk management or that an incident
report has been completed.
VIII. Incident Reports.
a. Your organization will have a policy about when an incident report must be
filled out.
b. Fill out the incident report as fully as possible as close to the time of the
incident as clinical care will allow.
c. Just state the facts. Do not draw any conclusions for why there was a bad
outcome. Do not blame anyone.
d. Never refer to it in the patient record.
IX. Other Record Keeping Issues
A. Emails & Text Messages
a. If you are going to communicate this way, have the patient/clients consent.
b. Generally this will only be used for appointments or basic information.
c. It should be understood that there will not be someone to respond 24/7 and if
there is an emergency the patient/client needs to contact 911 or go to an emergency
room.
d. If you are using an EHR it will be set up for what can be dealt with through
email.
B. Transcription and Speech Recognition Technology
a. Carefully review all transcribed documentation and edit as appropriate. It is
easy to make typographic errors.
b. Any boxes that are automatically checked in must be reviewed.
c. Prohibit notations that state dictated information was not reviewed. “Dictate
but not reviewed” indicates “I don’t take responsibility for what is here”
d. Only base clinical decision on information that has been authenticated.
e. Make sure flow charts are filled out and the ties properly charted.
f. Make sure the notes section gives a clear impression of how the patient is
doing.
C. Cutting and Pasting. Be careful to review and edit to be sure the information is
accurate and relevant to the patient visit. If not reviewed carefully, there is risk of
incorrect information, inaccurate coding, and propagation of false information, plus
unnecessary and improper notes. When CMS does audits, they are specifically
focusing on duplicate medication documentation, such as cutting and pasting, where
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multiple entries are exactly alike or similar to other entries in numerous patient charts,
which might reflect improper payment or fraudulent payment practices.
D. Addendum. Entries added to a health record to provide additional information in
conjunction with a previous entry. The addendum should be timely, noted as an
addendum, document the current, date, time, and reason the additional information is
being added to the record, and signed.
E. Correction. A correction is a change in the information meant to clarify inaccuracies
after the original document has been signed or rendered complete. In the EHR,
corrections may involve removing information from one record and posting it within
another within the electronic document management system.
If the information is in a paper record, draw a line through the incorrect entry and
annotate the record with the date, reason for the revision noted, and signature of the
person making the revision. Never use white out or try to change what had been
written.
F. Late Entry. A late entry is an addition the health record when a pertinent entry was
missed or was not written in a timely manner. The late entry should bear the current
date, time, and reason for the additional information being added and be signed.
G. Deletion. In the EHR a deletion is the action of permanently eliminating information
that is not tracked in a previous version. This is almost impossible to do.
X. Do Not
a. Do not criticize any care that has been given or criticize a provider.
b. Do not use the record as a battleground for disagreements, disparaging
remarks or accusatory comments.
c. Avoid the use of slag or euphemisms.
d. Do not spoil the record. Spoliation is the destruction or concealment of
evidence. Correcting, revising, tampering or adding a note to the medical record upon
learning of a legal action will not only undermine the credibility of the record and weaken
the defense. It may result in accusations of professional misconduct and potential civil
and criminal damages.
e. Do not chart a call to “Risk Management” or make any reference in the patient
record to filling out an “incident report”.
f. Do not change a record at the request of the patient or his/her attorney.
XI. How To Avoid Liability
a. Document timely and accurately the care that was provided.
b. Never alter a medical record. You can make additions or late entries, but note
the correct time.
c. Date and time all progress notes.
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d. Use standard abbreviations.
e. Write clear statements of thoughts and findings.
f. Document significant conversations and thought processes.
g. Carry through on plans and if not explain why not.
h. If you have a doubt about whether to enter something or what to enter,
discuss with your supervisor.
i. Do not make flippant statements to anyone including the family.
Chart as though someone’s life depends on your being accurate. It does.
The quality of care they receive is not only dependent on the skills of the care team, but
also on how the health care providers communicate with each other regarding the
patient’s condition.
Someone’s life is your responsibility as part of the team, during your shift. You can
make a real difference by just being attentive and being sure you record everything
accurately.
All providers should be able to look at the record and have a clear picture of how the
patient is doing at that point in time.
From a legal perspective:
The record will serve as the foundation of the case against your
organization and also as its defense.
A record never lies and never dies.
If it is not written down, it did not occur.
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