Medical Records

MEDICAL RECORDS …
IT’S NOT FICTION

Lorman Educational Services
Independence, Ohio
March 15, 2012

© 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com

Presenter
Thomas W. Hess
Th W H
Dinsmore & Shohl LLP
191 W. Nationwide Blvd., Suite 300
Columbus,
Columbus Ohio 43215
Phone: 614.227.4260
Fax: 614.628.6890
thomas.hess@dinsmore.com
thomas hess@dinsmore com


Do’s and Don’ts of Medical Records

a. Why Does Someone Sue a Health Care Provider?
 Actual emotional harm
 Perceived emotional harm
 Guilt transference
 Unrealistic expectations of patient outcomes
 Death of a loved one
 Greed
 Opportunity
Opport nit
 Witnessed verbal or physical abuse, neglect



b. What the Plaintiff Attorney Looks for in the Plan of
Care?
 Unsigned meds
 Signed meds for days patient was in the hospital
 Signed meds for days of the month that don’t exist
 Undocumented intake and output
 Documented tube feeding intake where the cc’s are exactly
cc s
the same for a long period of time
 Departmental battles



b. What the Plaintiff Attorney Looks for in the Plan of Care?
y
(cont'd)
 Inconsistencies between therapies, nursing, etc., without a reason
 Care plans, nurses notes, skin grids containing conflicting
information
 Pre and post dating, sighing or documenting
 Failure to notify MD, legal representative and patient of change in
MD
treatments
 Poor follow-up after a fall – lack of ongoing Nursing Assessment



b. What the Plaintiff Attorney Looks for in the Plan of Care?
(cont'd)
 Lack of response to pain
 Failure to follow company standards and procedures for patient care
 Failure to respond in a timely manner to change in condition of a
patient



c. What the Plaintiff Attorney Looks for to Win the
Case?
C ?
 Disgruntled ex-employees
 Unhappy current employees
 Witnessed altercations b t
Wit d lt ti between staff and patient or family
t ff d ti t f il
 High staff turnover
 Conflicting documentation
 Lack of integrity of staff
 Obvious falsification of the documentation
 Decline of the patient without fundamental interventions



c. What the Plaintiff Attorney Looks for to Win the Case?
(cont d)
(cont'd)
 History of non-compliance in the same area as the lawsuit
 Weight loss
 Multiple falls
 Falls with significant injuries
 Malnutrition and dehydration
 Sepsis caused by p
p y pressure sores
 Amputation related to gangrene
 Resident abuse



d. What to Do?
 Prioritize customer relations
 Seek customer feedback
 Follow-up on consumer complaints to the satisfaction of
the customer
 Encourage the use of the grievance procedure in your
facility
 Use family council as an opportunity to educate
 Develop family support groups relative to the types of
residents/patients in your facility


d. What to Do? (cont'd)

 Manage employee t
M l turnover
 Train staff to be proactive rather than reactive in their
approach to families
 Legal aspects of documentation should be part of
orientation for new employees
 Review marketing materials and strategies to be sure we
deliver what we promise

 Provide high quality care according to facility/company
standards
 Maintain a high quality documentation program


e. Documentation

 First line of attack
 First line of defense
 Best opportunity to demonstrate care given
 Who looks at your chart?
 Other staff
 Supervisors
 Families
a es
 Residents
 Criminal Investigators



e. Documentation (cont'd)

 Who looks at your chart?
 Attorneys
y
 Abuse, neglect investigators
 Surveyors
 Insurance companies payor sources (Medicare)
companies,



 Purpose of the Plan of Care
 The Plan of Care should provide evidence of the quality of
patient care
 DON’T just chart what happened
 DO
 Describe what has been done for the patient
 Give evidence that it was necessary
 Note the patient’s response to the care and any
changes made to the Plan of Care
 Identify the standards by which care was delivered
 Adhere to company standards and procedures
 Community important clinical information to other care
givers




 Before you chart
 Be familiar with requirements
 Know your company’s policies and procedures
 Read what was written during the last shift
 Common Sense Charting
 NEVER
 Use undecipherable handwriting



 C
Common S
Sense CCharting
 NEVER
 Use undecipherable handwriting
 Pre-chart: this makes the entire chart suspect
 Use the chart as a battleground with other
departments
 Use speculation
 Fail to chart tasks performed
 Obliterate documentation




 Common Sense Charting
 ALWAYS
 Chart facts
 Follow-up from previous documentation
 Document resident response to care using direct
quotes as much as possible
 U l t entries f omissions
Use late t i for i i




 All Chart Entries Should Be:
 Objective
 Ti l
Timely
 Factual
 Consistent
 Accurate
 Specific



 Tips for Charting
p g
 Use addendum’s and clarifications to avoid incorrect
interpretation of information
 Avoid having records split
 Document only those issues pertaining to the direct care of
the patient i the chart
h i in h h
 Establish standards for documentation and include in
employee orientation
 Avoid routine use of checklists
 Set strict policies on late entries
 Never speculate
 Avoid block charting



 Tips for Charting
 Avoid
A oid “Parrot” charting
 Avoid the use of non-quantitative terminology
 Take advantage of opportunity to “Paint a Picture” at
admission and upon discharge
 Don t
Don’t chart for others
 KEEP EMOTION OUT OF MEDICAL RECORD
 Change in condition – must be noted and charted until
resident/patient is stable or condition is resolved
 Documentation MUST show EVIDENCE of what you did
– FOLLOW THROUGH!!
 Documentation must show who you notified, (family,
physician, etc.) include date, time and all attempts made
 ALWAYS tell the truth




 Late Entry
 Identify documentation as a “late entry”
 Enter today’s date and time
today s
 Identify date and incident for which the late entry is
written
 If documenting an omission validate the source of the
additional information as much as possible
 When using a late entry, document ASAP




 Addendum
 Use an addendum to clarify existing documentation
 E t today’s date and ti
Enter t d ’ d t d time
 Identify date and incident for which the late entry is
written
 If documenting an omission validate the source of the
additional information as much as possible
 When using a late entry, document ASAP



 Actual Documentation Found in Patient Records
 Patient h
P ti t has chest pain if she li on h l ft side f over a year
h t i h lies her left id for
 On the second day the knee was better, and on the third day it
disappeared
 The patient has been depressed since she began seeing me in
1993
 Discharge status: Alive but without my permission
 Healthy appearing decrepit 69-year-old male, mentally alert but
forgetful
 The patient refused autopsy
 The patient has no previous history of suicides
 Patient has left white blood cells at another hospital
 Patient’s medical history has been remarkably insignificant with
only a 40 pound weight gain the past three days




 Patient had waffles for breakfast and anorexia for lunch
 She is numb from her toes down
 While in ER, she was examined, x-rated and sent home
 The skin was moist and dry
 Occasional, constant infrequent headaches
 Patient was alert and unresponsive
 Rectal examination revealed a normal size thyroid
 She stated that she had been constipated for most of her
p
life, until she got a divorce
 Both breasts are equal and reactive to light and
accommodation
 Examination of genitalia reveals that he is circus sized



 The patient was to have a bowel resection. However, he
took a job as a stock broker instead.
 The pelvic exam will be done later on the floor
 Patient was seen in consultation by Dr. Blank, who felt
we should sit on the abdomen and I agree
g
 Large brown stool ambulating in the hall
 Patient has two teenage children, but not other
abnormalities



 Do’s and Don’ts of Daily Charting
 DO
 DO read prior notes on the patient before caring for him
and before charting your care
 DO have the patient’s name and identifying number on
every page
 DO use concise phrases. Begin each sentence with a
capital letter
 DO write neatly and legibly
 DO make entries in consecutive order
 DO use ink
 DO sign each entry
 DO indicate patient non-compliance



 DO
 DO quote your patient when appropriate
 DO use accepted medical abbreviations and
terminology
 DO document action taken following indication of a
need for action
 DO be definite. Avoid “apparently,” “appears to be,”
etc.



 DON’T
 DON’T chart until you check the name on the patient’s
record
 DON’T discard notes that have errors on them. If a
page must be recopied, keep the original page in a
recopied
sealed envelope in the chart
 DON’T “clarify,” tamper with or otherwise add to notes
previously written
 DON’T erase, obliterate or white-out entries
DON T erase white out
 DON’T make subjective entries. Instead describe what
you see, hear, feel and smell
 DON’T use terms or abbreviations unless you are sure
o t e e act ea g
of their exact meaning



 DON’T
 DON’T chart procedures in advance
p
 DON’T wait until the end of the day to chart
 DON’T pull a chart by number only
 DON’T skip lines between entries or leave space at
p p
the end of an entry or before your signature
 DON’T criticize patients or other providers in your
notes




 FINALLY!!!
 Record audits must be a part of the everyday routine


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