The Art of Documentation - Crozer-Keystone Health System - PA

Document. Document. Document… The Art of Documentation

January 2010

Documentation in the medical record is generally viewed as a necessary task done for regulatory and/or billing purposes. True, care will not be reimbursed if not properly notated and justified in a patient’s medical record. True, regulatory bodies routinely review medical records to ensure timely completion, appropriate care and potential fraud. However, the number one reason to document WELL is patient continuum of care and patient safety. While the medical record is just one form of communication between caregivers it is a consistent tool that captures the chronology of care and treatment, who was involved, and outcomes. The medical record allows communication flow regardless of day/time and memorializes events and care provided.  

Often, you’ll hear “sloppy documentation, sloppy care.” While this is not necessarily true, sloppy documentation can lead to sloppy outcomes. Take for example a note written in cursive by the attending physician, which is misinterpreted by subsequent readers. The one four letter word in response to the question allergy on the assessment form reads as “none” yet in reality the word written is nuts. This is an important little word that left misinterpreted or unclarified could have serious residual effects. While illegible handwriting is a common theme of sloppy documentation, it is not the only contributory factor. Sloppy documentation goes beyond penmanship. Sloppy documentation also includes inconsistencies and discrepancies among care givers in the medical record. Inappropriate use of flow sheets and omissions of notes are also evidence of sloppy documentation. 

All entries in the medical records should include date/time/signature of author. When referring to another caregiver their specific name should be acknowledged.  Many records reflect “nurse aware” or “physician notified”. Exactly who are these professionals?  It is virtually impossible to confirm the identity of these individuals days or years later. Specificity is critical to patient care so assumptions can’t be made. Patient is: anxious, status quo, stable, doing well are all relative terms that can be interpreted differently. Describe what you smell (foul, strong, sweet), see (reddened area ¼ inch around incision), hear (rales, ronchi, gallops), or feel (warm, cool, raised bumps). 

In the age of technology, sloppy documentation can still be present in an electronic record. Take for example a electronic record whereby the ED physician types in a narrative and checks off the appropriate line items in the history/physical screen for his female patient. However, he inadvertently strikes extra keys, which check off additional line items in the computer screen, which reflect that this female patient has history of prostrate cancer. While there might not be any consequential harm to this patient from this note the situation begs the question - what else is inaccurate in this record?

The medical record belongs to the patient and he/she is entitled to access and/or a copy of it. It’s important to note that the records are also a legal document so be careful to only write the facts - completely, accurately, objectively and timely. It is a tool that is used and shared by many individuals during the patient’s course of stay/treatment and many years later. Do not label or judge patient, family, or other healthcare professionals. 

If a note needs to be redacted the appropriate steps need to be taken so it does not appear that the records were falsified or altered. Obviously, white out is unacceptable. Additionally, scribbling or blackening out the note is unacceptable. Simply draw one line through the word(s) in question, insert date/time when redacted, and sign. If someone else needs to know what was changed in the record then they should be promptly informed and a note should be entered in the records as to who notified, when notified, and by who. To illustrate the problem consider this scenario: A resident wrote a whole page of orders for patient A then  learned four hours later that the orders should have been for a different patient (patient B). He had pulled the wrong chart to document on.  Instead of properly redacting the orders he tore the page out and threw it away without telling anyone. He then promptly wrote the orders on the correct chart not knowing that the nurse had already administered the drugs as ordered. This behavior not only was unethical and unprofessional, but put everyone at risk. 

  • The patient was at risk for injury as the nurse should have been informed immediately of the error so proper intervention could have been considered re: medication errors. 
  • The nurse was at risk for allegation of practicing beyond her license as the chart should have been properly redacted to avoid the perception that the nurse administered meds without an order. 
  • The resident was at risk for fraudulent tampering and altering the medical record.

If an adverse event occurs which has an effect on the patient then it must be captured in the medical record. Falls, wrong studies, medication errors are typical examples of events involving patients. While efforts to strive for a safe environment and patient safety events can still occur which need to be addressed and documented immediately. The longer it takes to document an event in the record the greater perception that the note is written for defense purposes and your credibility is put into question. Remember, the record is a communication tool for patient care. Once an event is known it must be verbally communicated to the appropriate parties, including the patient, and documented in the medical record. The information captured in the record should be factual and chronological. A objective description of the event, the plan of action and interventions to address the event, who was notified of the event- “disclosure”, the patient’s/family’s response to your notification, and treatment/care related to the event should be found in the record. Note: an Event Report should also be completed, but it is a separate document and process than charting in the medical record.  

The old adage that if it wasn’t documented then it didn’t happen is often said. While this is not necessarily true, it is easily believed. The key is to ensure appropriate, comprehensive documentation. Omissions and lack of documentation suggests that the caregiver was inattentive or absent in the delivery of care.  However, remember what you write is more important than how much you write.  

Bottom line - documentation is about the patient and is reflection of your credibility.

Risk Management CME Questions and Answers  January 2010

Document. Document. Document...The Art of Documentation January 2010 (Questions)

Document. Document. Document...The Art of Documentation January 2010 (Answers)

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