Medical Charting Tips for Nursing Professionals to Avoid Malpractice Risk
All medical services provided to the patient must be clearly and precisely documented. Check out some important medical charting tips.
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It is important for any practice and specialty to properly document medical records, as it helps provide better patient care, makes available crucial evidence for malpractice suits and supports stringent medical record review. Records review process involves the plaintiff’s attorney looking for a possible breach in the standard of care, injury to the patient, and a connecting link between the two. Consider these medical charting best practices for nursing professionals to avoid the possibility of a malpractice claim Document accurately • • • • • • • •
Documentation must be thorough and precise; avoid gaps in the charting Notes must be customized for each patient State possible complications and adverse outcomes Record the time they observed something of significance Note down the time they communicated particular health information to the treating physician Keep nursing entries precise regarding the times documented Each entry must include the correct time and date Every entry must be signed using a complete signature including the license information
Be aware about forms • • • • •
Complete flowsheets or checklists without any blanks; check all boxes Clearly chart all medications administered Document discontinued medications and mark changed doses Accurately describe all unusual occurrences Nursing entries must clearly identify the physician or supervisor who was informed of a particular event
Document all patient and family concerns •
Any concerns expressed by the patient or her family must be clearly documented.
Use proper language in the notes • •
Avoid using argumentative, self-justifying, accusing or ambiguous language Defensive documentation could have a negative impact
Be careful about altering the medical record •
Include the date and time for any alteration made in the record
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• •
Care must be taken not to obliterate the original entry Note down any discussion with the patient
Document any medical mishap concisely • •
Never understate or hide a medical mishap Do not exaggerate or misinterpret such happenings
Focus on objective documentation •
Patient’s progress and other relevant observations must be objectively documented
Enter all the important warnings given to the patient • • •
Provide pertinent information when being discharged from the facility Failing to provide such information could lead to readmission and medical complications Make note of any non-compliance on the part of the patient
Include informed consent documentation • • •
A separate form must be used for the informed consent Document any lack of response from other healthcare professionals Note the information that was conveyed and include the time the person was notified
Physicians, nurses, and clinicians need to be aware about the potential of medical malpractice risk. Accurate medical documentation helps avoid the stress and expenses of medical malpractice litigation. Attorneys can also successfully handle any challenge posed by medical chart review and other scrutiny. Effective documentation is the best defense against erroneous malpractice charges.
www.mosmedicalrecordreview.com
(800) 670 2809