What are acceptable objectives of documentation Flashcards
“What are acceptable objectives of documentation”
Continuity of care
Communication btwn interdisciplinary team
Corporate compliance
Supervision purposes
Why are records important?
They are the best evidence
What are some measures that protect the credibility of your record?
Document promptly
Avoid defensive record keeping
What are the contents of pt records?
- Clinical findings (concise and consistent)
- Relevant history
- Positive/Negative findings
- Trends or changes in pts conditions
- Complications and unexpected outcomes
- Positive and negative findings that are customarily recorded in similar circumstances
- Complaints from the pts or families
- Sources of info other than the pt
- Evidence of pt non-compliance (lifestyle etc.)
- Throrough narcortic documentation
- Actions take (dx, tx, consent)
- Discharge instructions
- Important warnings given to pt or family
- Comments showing thought processes (potention complications, reasons for conclusions, recommendations from consultants, corrections for errors in the records).
What should your prescribing narcotics for chronic pain contain?
Detailed pain history, pain history from family, detailed physical exam, standard office pain tests, non-verbal signs of pain and effects on mental state, changes in ADLs to identify pain-related impairments, trial of non-narcotic analgesics, frequent F/U visits with repeat evals, checks with pharmacies on prescription fillings and CURES on controlled substances, eval of pt for drug abuse risk (DIRE score, past records review), consultation with or referral to pain specialist or pain clinic
What does informed consent consist of?
Nature of intervention
Alternative options
Risk/serious frequent complication
What are technical requirements in documentation?
- All appropriate boxes, blanks, or checklists required for completion of the record. Anything not filled in is presumed not done.
- Dates and time of entries
- Maintain all records in tight chronological order
- Timely cosignatures to show adequate supervision
- Legality of audio recordings of communications with pts. Recording should include pt verbally consenting to recording.
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What are appropriate documentation of discussions with pt or family
- Document warnings to pts and family
- Document pt’s refusal to accept recommended tx.
- Documenting a pts refusal to accept recommended treatment
- Documenting verbal notification to the pt that you made a mistake causing injury (statute of limitation)
- Documenting a pts threats to sue
How does one not appear negligent in terms of avoiding violation of a duty?
- Document actions taken after documenting an abnormality
- Read other clinician’s prior notes before documenting to avoid contradicting.
- Respond appropriately to record entries by others that require your actions.
- Beware of documentation that forces others into specific responses
- Establish a higher level of care when appropriate.
- Don’t bury important findings in routine narrative.
How do you record recommendations from consultants?
-Document consultations: informal or formal:
the purpose of the consultation/referral.
the seriousness/urgency of the consultation to the patient
the advice given by the consultant
For informal consultation: don’t name the consultant just the specialty.
What happens after the consultation’s advice?
Follow the consultant’s advice. If you deviate: provide additional info and get a modified opinion from the same consultant, get a second consultant’s opinion.
What words appear judgemental?
Substandard performance:
-aberrant, bad, defective, excessive, faulty, inadequate, incorrect, insufficient, miserable, mishandled, poor, problem, sloppy, substandard, undesirable, unnecessary, unsatisfactory, wrong
Blame:
-accidental, blame, careless, confused, erroneous, error, fault, foolish, inadvertent, misadventure, mistake, mix-up, negligent, regret, regretful, sorry, terrible, unfortunate
other words to avoid:
inadvertent, reassured
Other actions to document to prevent the assumption of negligence:
- Don’t describe a progressive process without a precise description
- Don’t document non-commital terms used defensively
- Put key pt comments into quotes
- Document perceptions, not assumptions
- Document poor medical outcome- without implying culpability or blame (no editorial); limit description of the harmful event to what happened and resist the temptation to explain, rationalize, or argue
- Don’t suggest an unlikely cause while not noting a more likely one.
- Following the injury, don’t document how careful you were prior to the injury.
- Don’t document blame directed towards another clinician
- Maintain legible records
- Use approved abbreviations
What to omit from a pts record?
- risk prevention activity: don’t document there’s an incident report
- omit documenting matters that have legal implications but have no direct value to pt care.
What diminishes the credibility of the record keeper?
- Unprofessional comments, avoid opinions you lack the expertise to give
- Altering and losing records.
What are some general communication principles?
Never lie to pts
You are not obligated to disclose everything
What kind of pts sue: parents of children, pt who we don’t have a good rapport, health care providers
Strong warnings are essential to assure pt compliance
Family is as important as the pt when communicating
What are the strongest motivations for a pt to see a lawyer:
Anger, surprise, suspicion of negligence, confusion of what really happened
How do you avoid surprising the pt?
Provide informed consent
Build rapport: explain, notify of negative findings that rule/out diagnoses, discuss inconveniences that cause no permanent injury, educate
What to do after a poor outcome?
- Coordinate the health care team’s explanation.
- Prompt pt/family contact
- Explain the cause accurately
- Don’t turn the blame to pt. Don’t respond to a threat to sue. Document their threat to sue.
- Contact pts who may be dissatisfied or have abruptly terminated their care through phone call.
Difference between reasonable errors of clinical judgment and negligence
Reasonable errors of clinical judgment:
reasonable under the situation. Anyone else with the same training could have done the same problem. Never apologize or express regret for your actions after a reasonable error of clinical judgment.
If it’s negligence, explain why it occurred.
Elements of negligence explanation
- Admit the mistake (don’t say you were negligent)
- Don’t make statements that are incorrect, inaccurate or deliberately misleading.
- Apologize sincerely
- Mitigate the injury if possible
- Waive the entire bill
- Explain changes you will make in how you practice in order to protect other patients.
- If the injury was serious, it’s usually best to send the pt elsewhere for future care.
What are important points on confidentiality of pt information?
- Whatever is the most restrictive, is the law that prevails (state, federal, HIPAA).
- Don’t communicate by email
- It’s a basis for revoking license
- Subpoenas and notice to consumer can be delayed 20 days.
