10 Tips to Streamline Medical Documentation and Manage your Risk Medical charts are needed for medical chart reviews for improving care and for legal use. Here are 10 tips to manage risk when preparing medical charts.
Patient medical records are retained in medical practices, hospitals and other healthcare organizations primarily to preserve patient information, communicate it when needed, and thereby support ongoing care for the patient. However, medical records are valuable legal documents as well, serving as evidence of the care provided and are used for purposes such as medical chart reviews. They are used as evidence in various legal proceedings such as medical malpractice lawsuits, Medicare/Medicaid
and
Workers’
Compensation
claim
determinations,
investigations related to regulatory compliance, and peer review issues among other things. A medical record that is prepared in a timely manner and maintained well will prove to be very helpful in successfully defending a lawsuit as well as in
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responding effectively to any complaints from regulatory authorities. It is mandatory that medical records are factually correct and legible. Given the significance of medical records, providers can adopt certain best practices and keep in mind some important considerations when preparing the medical documentation of their patients. 1. Get it right the first time itself: This is the best way to ensure accuracy and comprehensiveness. Whatever entries made must be complete and legible. Do not go for abbreviations. All elements of the patient visit and your impressions must be clearly documented. Remember that the patient’s medical chart must contain only patient notes, test results, consent forms, correspondence etc. related to the patient. General notes, peer review details, correspondence to your malpractice insurer and so on must never be included along with the patient notes. Do not include personal comments, jokes related to patients etc. in the medical record. 2. If you need to make corrections for the patient’s benefit, do so appropriately: Sometimes, you may have to make chart changes to protect a patient’s health status. For example, the patient may be allergic to one drug and the drug name may be wrongly entered in the chart. Such an error must be corrected or it could put the patient at risk. To correct such a mistake, make a single line through the incorrect entry so that the prior entry is not obliterated. Make the necessary correction. You should then sign, put the date and make a brief note why such a change was made. It is important not to use correction fluid or cut off parts of the record when altering it. Another possibility is your dictation may be wrongly interpreted. If the change is noticed before the dictation becomes part of the medical chart, i.e. when you are proofreading the dictation, it is best to make the change then itself and then include it in the final medical chart. Strike off the mistake with a single line, mark the erroneous part of the dictated note, make the correction, put your sign and date with a note as to why the change is required. In the case of electronic records, the changes must be authenticated. EHR systems must have an “audit trail” that tracks who make the change and the date of the correction. The system must be able
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to make the change without deleting the original note from view. Remember that any modification or correction should be made only to your own entries. If you have doubts regarding the notes made by other providers, ask them about it so that they can make the required changes. 3. Do not replace, destroy or rewrite the medical record: If you do so, you could be compromising the very integrity of the chart. Destroying medical records could be considered a violation of the law and a criminal offence. Deliberate alteration, destruction, or falsification of a medical record could be considered gross malpractice and bring penalties. 4. Ideally, patients should not be permitted to modify a physician’s entry unilaterally: A patient can request for a change to be made, but the physician must also agree that such a correction is necessary to correct an incomplete or inaccurate record. In other words, just because a patient is being difficult or argumentative regarding a particular entry, you cannot make the change. The better option, experts point out, would be to document the events including the discussion with the patient and/or medical staff. The patient’s objection to the entry can also be included as part of the medical record. 5. Document
all
medical
mishaps
concisely:
Do
not
exaggerate
or
misrepresent a medical mishap. Make sure that such unfortunate mishaps are neither concealed or understated, either. 6. Never belittle the patient’s condition: It is vital that you clearly document the patient’s mental condition, the worries they express, as well as those expressed by their family. Also, document the actions the nurse took to allay their concerns. 7. Document any lack of response from another provider: If you have contacted another provider and he/she doesn’t respond, make a note that the person was notified and the information conveyed. Document the time of such notification as well. 8. Be sure to document any evidence of non-compliance on the patient’s part: Informed consent documentation is compulsory. Use a separate form for the patient’s informed consent.
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9. Make note of all warnings given to the patient at the time of discharge: This will help avoid readmission and related complications that could be attributed to inadequate discharge instructions. 10. The medical chart must clearly convey any discussion with the patient regarding possible outcomes and complications: Apart from ensuring this, also avoid any mention in the record that could be interpreted as insensitive, uncaring or suggestive of negligence. When lawyers review medical records with the support of a medical chart review company, they would be looking for the patient’s injury details, any breach in standard care, and a causal link between the breach and the injury. Poorly written medical records increase the liability risk by providing the plaintiff’s attorney enough evidence to build his/her case. So, it is the onus of healthcare providers to keep their positions safe. For this they have to ensure that all information in the medical record is relevant and accurate, all changes made are dated and signed; the original entry is not obliterated; and any requests made by the patient and which they do not agree with are noted and dated in the medical chart. The medical office staff should be aware of your policy as regards medical record amendment. In case one of your staff members spots an error, he/she should notify you of the same, but never correct it on their own. While incomplete, illegible medical records increase your liability risk, well-documented and legible medical records can assist your defense in a malpractice lawsuit. -----------------------------------------------------------------------------------------------------Disclaimer: The information provided in this article is for general educational purposes only and has been sourced from reliable internet resources. It is not intended to provide professional medical or legal counsel, nor to constitute a “standard of care”.
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