Charting For Keeps


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

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Charting For Keeps

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