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Charting is a fact of life for providers; an integral part of the daily responsibilities of providing patient care. Considering all the users and uses of the clinical record in the diagram below, it is easy to appreciate just how much reliance is placed on record documentation for all aspects of patients care delivery and hospital operations.
While the clinical record serves many purposes, the primary function is to document the care of the patient to facilitate continuity of care among the many providers, current and future, who care for and treat the patient.
The medical record is also the legal business record for a healthcare organization and as such, needs to be maintained in a manner that complies with applicable State and Federal regulations, accreditation standards, and professional practice standards. From a claims perspective, good documentation is critical because lack thereof can create costly rebuttal challenges and settlement recommendations in cases that, under normal circumstances, would not survive the discovery process. Litigation often takes years, during which time memories grow dim leaving the record as the prima facie evidence. Consequently, documentation can be your best defense or your biggest liability.
“Present on Admission” has recently taken on a whole new meaning with respect to DRG reimbursement. Effective October 1, 2008, the Centers for Medicare and Medicaid (CMS) has identified several hospital-acquired conditions as preventable events and plans to withhold reimbursement for these secondary diagnoses. The conditions in this first round of proposed reduced DRG payments include 1.) object left in during surgery ,2) air embolism, 3) blood incompatibility, 4 )catheter associated urinary tract infection, 5)pressure ulcer,
6) vascular catheter associated infections, 7) mediastinitis after coronary artery bypass graft, and 8) falls with associated trauma such as fracture, dislocation, intracranial bleeds, and crushing injuries. Additional conditions slated to be added in 2009 include 9) ventilator associated pneumonia, 10) staphylococcus aureus septicemia, and 11) deep vein thrombosis/pulmonary embolism. Clearly, any successful appeal attempts will depend in large part on the thoroughness of admission assessments and the adequacy of documentation relative to care plans and treatment provided to prevent these conditions if acquired during the patient’s stay.
Incorporating some of the following general documentation guidelines into an everyday routine is a good starting point:
1. Medical record entries should be legible and complete. Illegible handwriting impedes effective communication among the health care team and increases the potential for error and/or delays in implementing treatment and medication orders.
Use of dictation, pre-printed order sheets and computerized medication administration records can help resolve issues associated with poor penmanship. The steady transition toward electronic record systems is also useful in this regard and importantly, enables simultaneous access by multiple providers. Follow your facility policies and medical staff rules and regulations with respect to documentation requirements and time frames for completion.
2. Documentation content should be specific, objective and complete. The record should reflect factual information (what is known versus what is thought or presumed), charting objective facts rather than personal opinion, using quotation marks when quoting the patient. It is important to document complete facts and pertinent information related to the patient’s condition, history of past and present illnesses, examination and tests, hospital course and results of treatment, consults and any complications. The discharge summary should include the recovery status of the patient and all discharge instructions given to the patient and/or family. All significant communications with patients and all instances of noncompliance or refusals of treatment should be documented. Avoid generalizations and vague words such as: appears to be, as usual, status quo and the like. When documenting unplanned events, do not make reference to an “incident report” or “risk management notified” or assign blame to anyone. Simply document whatever occurred objectively.
3. Patient record entries should be documented at the time care and treatment is rendered. It is always good practice to chart contemporaneously while information is fresh. All entries should be written in blue or black ink, dated, timed and authenticated. It is also important that dictation be read, blanks filled in and corrected as indicated prior to signing. “Late entries”do not tend to have the same perception of credibility in court as a record that clearly documents the chronology of events. However, when making a late entry, identify it as such, putting the current date and time, referencing the date for which the late entry is written and if used to document an omission, validate the source of the additional information to the extent possible.
4. Correct Errors Properly. When a charting error is made, draw a single line through the entry so that the inaccurate information is legible, write “error” by the incorrect entry, sign and date the entry and document the correct information. To avoid suspicion of record tampering, do not obliterate or otherwise alter the original entry by blacking out, whiting out or writing over an entry. It is also good practice not to leave blank spaces on a sheet before starting a new page unless a line is drawn through the empty space to show it was intentionally left blank.
Good documentation can help protect your patients, other providers who rely on your documentation and you in the event of a malpractice claim.
“The spoken word perishes, The written word remains.”
Latin Proverb
References:
Update: Maintaining a Legally Sound Health Record Paper and Electronic
Documentation Requirements for the Acute Care Inpatient Record (AHIMA practice brief)
Hospital –Acquired Conditions in Acute Inpatient Prospective Payment System
Present on Admission Indicator Reporting by Acute Inpatient Prospective Payment System Hospitals
Self-Insurance Programs
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