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Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
Charting For Keeps
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Charting For Keeps

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Charting for more than negligence. Charting tips to defend payor audits, investigations, and allegations of professional misconduct.

Charting for more than negligence. Charting tips to defend payor audits, investigations, and allegations of professional misconduct.

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  • 1. Charting for Keeps MK Gaedeke Roland, RN, MSN, JD Associate General Counsel Kaleida Health
  • 2. Objectives
    • Discuss the importance of correct time and date
    • Recognize the implications of unclear chart entries
    • Describe the dangers of conclusions, characterizations, and opinions
    • Apply charting problems to litigation and professional licensing
  • 3. Charting Your Course
    • Why is accurate and complete charting so important?
      • To avoid errors
      • To support your assessments and interventions
      • To communicate to other health care providers and assure continuity of care
      • To “refresh your recollection”
      • To paint an impression
      • To survive audits by payors
      • To survive challenges to your license
  • 4. Charting Your Course
    • Why is legible charting so important?
      • Illegibility may give the impression of
        • Carelessness
        • Secrecy
      • Payors will deny payment
      • Medical errors may be made
  • 5. Timing is everything
    • NEVER chart in advance
  • 6. Timing is everything
    • Chronology, chronology, chronology
      • Date and time each entry. Be sure to always include the year
      • Assure all entries are in order
      • NEVER redate an entry
      • Any addenda or corrections must be dated on the date the addenda or correction was created
  • 7. Timing is everything
    • Generally, begin statements with the time reference to avoid misunderstandings or the bizarre
      • Patient has chest pain if she lies on her left side for over a year
      • The patient has been depressed ever since she began seeing me in 1983.
  • 8. Everything has its place
    • Be sure to chart in the appropriate areas of the medical record
    • Make sure everything is promptly filed
    • Do not include incident reports, personal notes, investigation materials
  • 9. Everything has its place
    • The pelvic exam will be done later on the floor
    • She is numb from her toes down
    • When she fainted, her eyes rolled around the room
  • 10. Oxymorons
    • Seriously, did professionals really write this stuff?
      • The skin was moist and dry
      • The patient suffers from occasional, constant, infrequent headaches
      • Both breasts are equal and reactive to light and accommodation
      • Healthy-appearing decrepit sixty-nine year old male, mentally alert but forgetful.
  • 11. Abbreviations
    • A hard habit to break, but…..
      • JCAHO frowns on them
      • They often lead to medical errors
        • QD/QID/QOD
        • R ear drops
      • “ We will follow her eyes and nose with a foley catheter”
      • “ Large brown stool ambulating in the hall.”
  • 12. “It”, “He”, “She”, “They” . . .
    • “On the second day the knee was better and on the third day it had completely disappeared.”
    • “During the patient care conference, they expressed concern about the current treatment plan.”
  • 13. Passive voice
    • We’ve all been taught ( why? ) to write in the passive voice. It is misleading and unclear.
      • “ The patient was seen today for his complaint of dizziness.” Who saw the patient?
      • “ It was decided that the patient should not be referred for transplantation.” Who decided? Why?
      • “ The patient’s lab results were reviewed and new orders written”
  • 14. If you haven’t got something nice to say…..
    • Don’t put your personal opinions about patients or their family and friends in the medical record
    • Don’t record your anger with other care providers
  • 15. Theory of Relativity
    • Without supporting documentation, conclusions can be challenged
      • Wound is healing
      • Patient is ambulating better
      • Patient’s appetite is increased
      • Edematous
    • Where is the assessment?
  • 16. Honesty is the best policy
    • NEVER, never obliterate or destroy an entry
    • NEVER, never add an entry out of sequence without CLEARLY noting the time and date the new entry is made
    • If the entry is detrimental to you or the institution, it is FAR more detrimental if an entry is falsely changed or added
  • 17. Templates
    • Pros
      • Helps guide caretaker in what should be recorded
      • Saves time
    • Cons
      • Less individualized
      • MCFU dislikes templates
      • Lacks pertinent negatives
  • 18. Because, because, because…..
    • We are licensed and paid for our unique knowledge and expertise
      • Chart what and why , especially for prns
      • Always be sure the chart reflects the reasons for your interventions to avoid an appearance of “routine” or “automatic”
      • Always be sure the chart reflects the results of your interventions. Did the interventions work?
  • 19. Current enforcement
    • Nutrition and weight
    • Skin care
    • Care plans
    • Continuing medical necessity for long-term conditions
  • 20. Let’s improve these…..
    • The patient was fed dinner
    • Medicated for pain
    • Patient grouchy and uncooperative
    • Wife is belligerent
    • It was decided to discontinue treatment

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