MEDICAL RECORDS …IT’S NOT FICTIONLorman Educational ServicesIndependence, OhioMarch 15, 2012                              ...
Presenter  Thomas W. Hess  Th      W H  Dinsmore & Shohl LLP  191 W. Nationwide Blvd., Suite 300  Columbus,  Columbus Ohio...
Do’s and Don’ts of Medical Recordsa.   Why Does Someone Sue a Health Care Provider?        Actual emotional harm        ...
Do’s and Don’ts of Medical Recordsb. What the Plaintiff Attorney Looks for in the Plan of   Care?     Unsigned meds     ...
Do’s and Don’ts of Medical Recordsb.   What the Plaintiff Attorney Looks for in the Plan of Care?                         ...
Do’s and Don’ts of Medical Recordsb. What the Plaintiff Attorney Looks for in the Plan of Care?   (contd)     Lack of res...
Do’s and Don’ts of Medical Recordsc.   What the Plaintiff Attorney Looks for to Win the     Case?     C   ?        Disgru...
Do’s and Don’ts of Medical Recordsc. What the Plaintiff Attorney Looks for to Win the Case?   (cont d)   (contd)       Hi...
Do’s and Don’ts of Medical Recordsd. What to Do?      Prioritize customer relations      Seek customer feedback        ...
Do’s and Don’ts of Medical Recordsd. What to Do? (contd)              Manage employee t               M              l   ...
Do’s and Don’ts of Medical Recordse. Documentation      First line of attack      First line of defense      Best oppor...
Do’s and Don’ts of Medical Recordse. Documentation (contd)    Who looks at your chart?      Attorneys               y   ...
Do’s and Don’ts of Medical Recordse.   Documentation (contd)      Purpose of the Plan of Care         The Plan of Care s...
Do’s and Don’ts of Medical Recordse. Documentation (contd)     Before you chart        Be familiar with requirements    ...
Do’s and Don’ts of Medical Recordse.   Documentation (contd)      C       Common S              Sense CCharting         ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)        Common Sense Charting          ALWAYS             Cha...
Do’s and Don’ts of Medical Recordse. Documentation (contd)        All Chart Entries Should Be:          Objective       ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Tips for Charting         p              g           Use...
Do’s and Don’ts of Medical Recordse. Documentation (contd)       Tips for Charting             Avoid              A oid ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Late Entry        Identify documentation as a “late entr...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Addendum        Use an addendum to clarify existing docu...
Do’s and Don’ts of Medical Recordse.   Documentation (contd)        Actual Documentation Found in Patient Records        ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Actual Documentation Found in Patient Records          P...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Actual Documentation Found in Patient Records        The...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Do’s and Don’ts of Daily Charting          DO           ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)       Do’s and Don’ts of Daily Charting           DO         ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      Do’s and Don’ts of Daily Charting          DON’T        ...
Do’s and Don’ts of Medical Recordse.   Documentation (contd)        Do’s and Don’ts of Daily Charting          DON’T    ...
Do’s and Don’ts of Medical Recordse. Documentation (contd)      FINALLY!!!        Record audits must be a part of the ev...
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Medical Records

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Medical Records

  1. 1. MEDICAL RECORDS …IT’S NOT FICTIONLorman Educational ServicesIndependence, OhioMarch 15, 2012 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  2. 2. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  3. 3. Do’s and Don’ts of Medical Recordsa. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  4. 4. Do’s and Don’ts of Medical Recordsb. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  5. 5. Do’s and Don’ts of Medical Recordsb. What the Plaintiff Attorney Looks for in the Plan of Care? y (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  6. 6. Do’s and Don’ts of Medical Recordsb. What the Plaintiff Attorney Looks for in the Plan of Care? (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  7. 7. Do’s and Don’ts of Medical Recordsc. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  8. 8. Do’s and Don’ts of Medical Recordsc. What the Plaintiff Attorney Looks for to Win the Case? (cont d) (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  9. 9. Do’s and Don’ts of Medical Recordsd. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  10. 10. Do’s and Don’ts of Medical Recordsd. What to Do? (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  11. 11. Do’s and Don’ts of Medical Recordse. 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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  12. 12. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Who looks at your chart?  Attorneys y  Abuse, neglect investigators  Surveyors  Insurance companies payor sources (Medicare) companies, © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  13. 13. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  14. 14. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  15. 15. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  16. 16. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  17. 17. Do’s and Don’ts of Medical Recordse. Documentation (contd)  All Chart Entries Should Be:  Objective  Ti l Timely  Factual  Consistent  Accurate  Specific © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  18. 18. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  19. 19. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  20. 20. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  21. 21. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  22. 22. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  23. 23. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Actual Documentation Found in Patient Records  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  24. 24. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Actual Documentation Found in Patient Records  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  25. 25. Do’s and Don’ts of Medical Recordse. Documentation (contd)  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  26. 26. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Do’s and Don’ts of Daily Charting  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. © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  27. 27. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Do’s and Don’ts of Daily Charting  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  28. 28. Do’s and Don’ts of Medical Recordse. Documentation (contd)  Do’s and Don’ts of Daily Charting  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 © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com
  29. 29. Do’s and Don’ts of Medical Recordse. Documentation (contd)  FINALLY!!!  Record audits must be a part of the everyday routine © 2011 DINSMORE & SHOHL | LEGAL COUNSEL | www.dinsmore.com

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