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Documentation in medicine and Legal Challenges


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Documentation in medicine and Legal Challenges

  1. 1. MEDICAL DOCUMENTATION&LEGAL CHALLENGESDr.T.V.Rao.MD5/29/2013 Dr.T.V.Rao MD @ health care 1
  2. 2. Medical Law is Part of MedicalPractice• Medical law plays an important role inmedical facility procedures and the waywe care for patients. We live in a litigioussociety, where patients, relatives, andothers are inclined to sue health-carepractitioners, health-carefacilities, manufacturers of medicalequipment and products, and otherswhen medical outcomes are notacceptable 25/29/2013 Dr.T.V.Rao MD @ health care
  3. 3. Medical Law and Ethics• In order to understand medical law and ethics, itis helpful to understand the differences betweenlaws and ethics.• A law is defined as a rule of conduct or actionprescribed or formally recognized as binding orenforced by a controlling authority.Governments enact laws to keep societyrunning smoothly and to control behaviour thatcould threaten public safety.35/29/2013 Dr.T.V.Rao MD @ health care
  4. 4. Ethics and Behaviour• Ethics isconsidered astandard ofbehaviour and aconcept of rightand wrong beyondwhat Legal andEthical Issues inMedical Practice, 45/29/2013 Dr.T.V.Rao MD @ health care
  5. 5. Introduction• Medical records document the evaluationand treatment of patients–Critical to patient care–Legal document• Medical assistants and nurses has a majorrole in documenting in and maintainingpatient records5/29/2013 Dr.T.V.Rao MD @ health care 5
  6. 6. What is Documentation• Anything writtenor printed• Relied on as arecord of proof forauthorizedpersons• Vital part ofprofessional practice65/29/2013 Dr.T.V.Rao MD @ health care
  7. 7. Documentation MattersClinicalDocumentationin the MedicalRecord shouldbeCompleteLegibleTimelyConciseClearPatientCenteredAccurate7In a nut-shell
  8. 8. Documentation MattersContent of Medical RecordDischarge SummaryHistory & PhysicalProgress NotesNursing NotesOperative Reports, if anyMedication RecordFlow ChartsLab & Radiology ReportsOrders8Content of Medical Record Discharge Summary History & Physical Progress Notes Nursing Notes Operative Reports, if any Medication Record Flow Charts Lab & Radiology Reports Orders
  9. 9. Purposes of Documentation• Quality of care–provides evidence that care was necessary–( Eg You do a Operative Procedure )– describes responses to care– describes any changes made in plan of care• Coordination of care– plan interventions– decision making about ongoing interventions– evaluation of patients progress– used by all team members95/29/2013 Dr.T.V.Rao MD @ health care
  10. 10. Why is clinical documentation important?• Documentation is critical for patientcare.• Serves as a legal document• Quality Reviews• Validates the patient care provided• Impacts coding, billing andreimbursement105/29/2013 Dr.T.V.Rao MD @ health care
  11. 11. Purposes of Documentation inMedicine–Clinical recordsare reviewed toensure the facilitymeets therequiredstandardsassessed forongoingcompliance115/29/2013 Dr.T.V.Rao MD @ health care
  12. 12. Importance of Medical Documentation• Proper and adequatemedical documentationis essential for qualityof medical care andhealth care servicesthroughout theindustry, fromreceiving proper andcorrect treatment125/29/2013 Dr.T.V.Rao MD @ health care
  13. 13. Fill the Patient Charts:Standard Chart Information (cont.)• Physical examination results• Results of laboratory andother tests• Records from otherphysicians or hospitals– Include a copy of the patientconsent authorizing releaseof information5/29/2013 Dr.T.V.Rao MD @ health care 13
  14. 14. Every Case sheet should contain aMinimal Data• Personal info:age, sex, occupation, training, family...• Risk factors: tobacco, alcohol, life styles...• Allergies and drug reactions• Problem list• Disease history: diseases, operations. . .• The disease process: mainproblem, history, exam, lab.• Management plan: advice, education, medication.. . 145/29/2013 Dr.T.V.Rao MD @ health care
  15. 15. Medical DocumentsDoctors author Records• Medical documentationor documentation of amedical conditionmeans a statementfrom a licensedphysician or otherappropriate practitionerproviding informationthe agency considersnecessary.155/29/2013 Dr.T.V.Rao MD @ health care
  16. 16. Function of Medical Documentation isImportant When Referring Patients• Why is important medical documentationvital?Without it, your health care would becompromised. HOWOne doctor wouldnt know whatanother doctor was doing. Withoutadequate documentation of visits, labtests, treatments or surgeries, quality ofcare would certainly be erratic andpotentially deadly. 165/29/2013 Dr.T.V.Rao MD @ health care
  17. 17. Documentation increasesPatient Care• The medicalrecordchronologicallydocuments thecare of the patientand is animportant elementcontributing tohigh quality care. 175/29/2013 Dr.T.V.Rao MD @ health care
  18. 18. Ethics and Documentation• Adequate medical documentationassures patient confidentiality andensures that standards of care are beingmet.Doctors and other medical personnelhave an obligation to treat illnesses tothe best of their ability in regard toinformation documented in a patientsmedical record.185/29/2013 Dr.T.V.Rao MD @ health care
  19. 19. Patients Health Care Information aVital Document• The patients history isa vital piece ofinformation thatenables physicians todetermine the bestdiagnosis andtreatment plan forthat individual, basedon information foundin the medical record.195/29/2013 Dr.T.V.Rao MD @ health care
  20. 20. Must contain Subjective/History• Past Medical History (PMH)– Medications Allergies– Allergies Medications– Illnesses Pertinent past history– Doctor Last oral intake– Surgery Events leading to illnessor injury205/29/2013 Dr.T.V.Rao MD @ health care
  21. 21. Common standards forDocumentation•assessment•plan of caremedicalorders•progressnotes•dischargesummary 215/29/2013 Dr.T.V.Rao MD @ health care
  22. 22. Skills Used in Documentation•Cognitive•TechnicalInterpersonalEthical/Legal225/29/2013 Dr.T.V.Rao MD @ health care
  23. 23. A Documents of all Critically illpatients be given due care in filing• Clinical findings from the most recentmedical evaluation, including any ofthe following which have beenobtained: Findings of physicalexamination; results of laboratorytests; X-rays; EKGs ECG, MRI, CTScans and other special evaluationsor diagnostic procedures; 235/29/2013 Dr.T.V.Rao MD @ health care
  24. 24. Psychiatric evaluation andDocumentation• In the case ofpsychiatric evaluation ofpsychologicalassessment, thefindings of a mentalstatus examination andthe results ofpsychological tests, ifappropriate must befiled with due care245/29/2013 Dr.T.V.Rao MD @ health care
  25. 25. Blood AdministrationDocumentation• Needs cautious Documentation– Blood Administration Verification (completed just prior to startinginfusion)– Blood Product Infusion (start time and initial rate)– Infusion Changes (any rate changes duringinfusion)– Blood Product Completion (completed at end ofinfusion)– Blood Vital Signs (baseline vitals taken atstart, then q15min x 2 after initiation, thenhourly)
  26. 26. Good Documentation Increases LegalProtection• Peer review• Requirements forreimbursement• Legal protection• Research &continuingeducation265/29/2013 Dr.T.V.Rao MD @ health care
  27. 27. Patient Records Helps in PlanningYour Future Actions• Communication• Care Planning• Quality Review• Research• Decision Analysis• Education• Legal Documentation• Reimbursement275/29/2013 Dr.T.V.Rao MD @ health care
  28. 28. Residents should Document• Computer-basedRecords–Standardization–Legible–Follow policiesand procedures toensureconfidentiality285/29/2013 Dr.T.V.Rao MD @ health care
  29. 29. Fill all Laboratory Requests withSense of ResponsibilityName xxxx Age SexIP/ OP No xyz Time DateWard xx123 Urgent / RoutineNature of specimenInvestigation neededBrief Clinical findingsDoctor/StaffContact No 12345675/29/2013 Dr.T.V.Rao MD @ health care 29
  30. 30. Rules in keeping medical records as it requiresConfidentiality1. Personal biographical data include the address, employer, homeand work telephone numbers and marital status.2. All entries in the medical record contain the author’s identification.Author identification may be a handwritten signature, uniqueelectronic identifier or initials.3. All entries are dated.4. The record is legible to someone other than the writer.5. *Significant illnesses and medical conditions are indicated on theproblem list.6. *Medication allergies and adverse reactions are prominentlynoted in the record. If the patient has no known allergies or historyof adverse reactions, this is appropriately noted in the record.305/29/2013 Dr.T.V.Rao MD @ health care
  31. 31. Patients Records are confidentialdo not discuss without purpose315/29/2013 Dr.T.V.Rao MD @ health care
  32. 32. Critical Lab ValuesDocumentationProcedure1. Verify the result by verbally reading theresult back to the technologist/technician2. Notify the nurse assigned to the patient ofthe critical result if she/he was not the oneto receive the telephonic notification.3. Document receiving the phone call aboutthe critical value, the critical result, and whatyou did about the result on the Critical LabValues
  33. 33. Correct your Mistakes with Sense andLegality• Never usewhitener• Never scratch out• Draw a linethrough themistake• Initial above themistake 335/29/2013 Dr.T.V.Rao MD @ health care
  34. 34. Correcting Patient Records• When mistakes happen, correctthem immediately– Draw a line through the originalinformation• It must remain legible– Insert correct information aboveor below original line or in margin– Document why correction was made– Date, time, and initial correction– Have a witness, if possiblem/d/yyyy 00:00pmmisspelled JHC/chj5/29/2013 Dr.T.V.Rao MD @ health care 34
  35. 35. Document the Patient Record withInstitutional Protocols• Initial evaluation• Age and gender (Pt. is 20 y.o. white• male)• Prior level of function (including• occupation/ functional status• Social history (Lifestyle, home• situation, home accessibility)• Emotions/attitudes• Direct quotes (to illustrate• confusion, denial, attitudes, etc.)• Chief complaints or complains of• MOI• Onset (insidious or traumatic)• DOI 355/29/2013 Dr.T.V.Rao MD @ health care
  36. 36. Verification of Physician Orders• For ancillary department orders requiringpager notification (Respiratory Therapy)the time of the page is written on theorder sheet next to the order• Co-sign each set ofphysician orders withinitials, title, date, and time
  37. 37. Documentation Standards Vary fromSituation and Specialties• Pain scale (1-10)• Location and type of pain (burning,• stinging, sharp, dull, radiating, etc.)• Aggravates and alleviates pain• Details since onset (history of• injury)• PMHx• PRx (Past treatment)• Date of surgery (DOS)• Special tests (x-rays, MRI, CT scan)• Rule out• Meds and allergies• Patient and/or family goals375/29/2013 Dr.T.V.Rao MD @ health care
  38. 38. Nursing Notes• Nursing notes are entered ona patient in the following situations:– Admission– Transfer– Discharge– When an unusual event occurs or with change ofpatient status– When an appropriate intervention cannot befound to document on5/29/2013 Dr.T.V.Rao MD @ health care 38
  39. 39. Record all the Progress of the Patient– As Things can go Wrong ?• Response to treatmentand rehab.• Reassessing subjectiveinformation fromprevious notes• Change in function• Change in pain(location, type)• Patient complianceissues395/29/2013 Dr.T.V.Rao MD @ health care
  40. 40. Medical law• Medical law plays an important role inmedical facility procedures and the waywe care for patients. We live in a litigioussociety, where patients, relatives, andothers are inclined to sue health-carepractitioners, health-carefacilities, manufacturers of medicalequipment and products, and otherswhen medical outcomes are notacceptable. 405/29/2013 Dr.T.V.Rao MD @ health care
  41. 41. We are sued in spite of BestPractices415/29/2013 Dr.T.V.Rao MD @ health care
  42. 42. Critical comments in Writing isDangerous•Do not write retaliatory orcritical comments; do notplace blame on yourcolleagues•Spell correctly5/29/2013 Dr.T.V.Rao MD @ health care 42
  43. 43. Infighting of Doctors and NursesA concern and Dangerous435/29/2013 Dr.T.V.Rao MD @ health care
  44. 44. Who Are Prone to Litigations• Obstetrics lead the way in being themost litigation prone medical specialty.Surgery takes the second place followedby internal medicine paediatrics beingthe fourth in order of frequency. Leastnumber of malpractice lawsuits werefiled against the dental profession5/29/2013 Dr.T.V.Rao MD @ health care 44
  45. 45. Court Believes your Documentsonly• Documentcompletely [incourt - if itsnotdocumented,it wasnt done455/29/2013 Dr.T.V.Rao MD @ health care
  46. 46. Legal Aspects of Charting• Be accurate about time &chart as soon as possibleafter an event• Document omissions (mednot given or treatment notcompleted) & reason &actions taken• Do not leave blankspaces• Record legibly & inblack ballpoint pen465/29/2013 Dr.T.V.Rao MD @ health care
  47. 47. Legal Aspects of Charting• Use only approvedabbreviations• Record clarificationrequests &/orcorrections• Avoid vague statement• Begin with time andend with appropriatesignature475/29/2013 Dr.T.V.Rao MD @ health care
  48. 48. 48• Record everything you do(including phone consultations)• Apply guidelines LEARNFROM YOUR SENIORS ORCONSULTANTS•Dont use erasable pencils• Don’t use humiliatingexpressionsIn order to prevent legalproblems:5/29/2013 Dr.T.V.Rao MD @ health care
  49. 49. Why to keep records?• Helps in medical decisions(is the size of a lymph node or noduleincreasing with time?)• Helps to share responsibility with thepatient• Legal obligation.• Protects the patient as well as doctor infront of the court495/29/2013 Dr.T.V.Rao MD @ health care
  50. 50. Still you want to Correct the Errors• Make a notation explaining thecorrection, or directing thereader to the appropriateaddendum. Date and sign thecorrection. If using anaddendum, place it in sequenceor chronological order505/29/2013 Dr.T.V.Rao MD @ health care
  51. 51. Updating Patient Records• Additions to record shouldnot appear deceptive– Document why late entry ismade– Date and initial added items• May have a third partywitness additionAddition made to recordbecause patient called backwith additionalinformation.Mm/dd/yyyy – JHC / chj5/29/2013 Dr.T.V.Rao MD @ health care 51
  52. 52. Release of Records (cont.)• Procedures for releasing records–Obtain a signed and newly dated releaseform authorizing the transfer ofinformation, and placeit in the patient’s record–Make photocopies of original materials• Copy and send only documents covered in therelease authorization–Call to confirm receipt of materials5/29/2013 Dr.T.V.Rao MD @ health care 52
  53. 53. Hand over the Matters whenchanging the Shifts• Change-of-shift report– Accurate information– Factual information– Organized– What & how you say it canmake a big difference inquality of care– Avoid negativism &subjectivity– Use written or printedguide to promptthoroughness &organization535/29/2013 Dr.T.V.Rao MD @ health care
  54. 54. Medical Billing and Coding NeedsDocumentation• Without adequate medicaldocumentation, yourhealth care providersmight not be reimbursedfor providing you withcare, leaving you stuckwith the bill. Theres an oldsaying in the health careindustry: "If its notdocumented, it didnthappen. 545/29/2013 Dr.T.V.Rao MD @ health care
  55. 55. Malpractice claims• Malpractice claims are lawsuits by apatient against a physician for errors indiagnosis or treatment. Negligence casesare those in which a person believesthat a medical professional did notperform a essential action or performedan improper one, thus harming thepatient.5/29/2013 Dr.T.V.Rao MD @ health care 55
  56. 56. Following are some examples ofMalpractice:• Postoperative complications. Forexample, a patient starts to showsigns of internal bleeding in therecovery room. The incision isreopened, and it is discovered thatthe surgeon did not complete closureof all the severed capillaries at theoperation site.5/29/2013 Dr.T.V.Rao MD @ health care 56
  57. 57. When documenting Spell theWords Correctlymedication names575/29/2013 Dr.T.V.Rao MD @ health care
  58. 58. Last But Not the LeastDo not miss spell the wordsIt is Your Identityclavicleclavical58X5/29/2013 Dr.T.V.Rao MD @ health care
  59. 59. • Computer records– Accuracy is also important with electronicrecords– Advantages• Can be accessed by more than oneperson at a time• Can be used in teleconferences• Useful for tickler files– Security concerns• Protect patient confidentialityAppearance, Timeliness, andAccuracy of Records (cont.)5/29/2013 Dr.T.V.Rao MD @ health care 59
  60. 60. Excellence in Medical Documentation ReducesMalpractice Allegations• Excellence in medical documentationreflects and creates excellence in medicalcare. At its best, the medical recordforms a clear and complete plan thatlegibly communicates pertinentinformation, credits competent care andforms a tight defense against allegationsof malpractice by aligning patient andprovider expectations.5/29/2013 Dr.T.V.Rao MD @ health care 60
  61. 61. Respect the Privacy of the Patients5/29/2013 Dr.T.V.Rao MD @ health care 61
  62. 62. Documentation Matters“If it was not documented, it was not done”5/29/2013 Dr.T.V.Rao MD @ health care 62
  63. 63. Today is Different from Yesterday• In today’ssociety, medicaltreatment and decisionssurrounding health carehave become complex.It is therefore importantto be knowledgeableand aware of the issuesand the laws thatgovern patient care.635/29/2013 Dr.T.V.Rao MD @ health care
  64. 64. Error is Human Even in wellDeveloped Countries• Health care in the United States is not as safe as itshould be--and can be.• At least 44,000 people, and perhaps as many as98,000 people, die in hospitals each year as a resultof medical errors that could have beenprevented, according to estimates from two majorstudies.• Even using the lower estimate, preventable medicalerrors in hospitals exceed attributable deaths to suchfeared threats as motor-vehicle wrecks, breastcancer, and AIDS5/29/2013 Dr.T.V.Rao MD @ health care 64
  65. 65. MEDICINE is a TEAM WORK655/29/2013 Dr.T.V.Rao MD @ health care
  66. 66. Doctors are Observed Closely byeveryone5/29/2013 Dr.T.V.Rao MD @ health care 66
  67. 67. My Teachers told …….Best Policy to reduce Litigations is5/29/2013 Dr.T.V.Rao MD @ health care 67
  68. 68. Your Scientific Documentation saves you fromMany Litigations and Saves our Job685/29/2013 Dr.T.V.Rao MD @ health care
  69. 69. • The programme Created by Dr.T.V.Rao MD forMedical Professionals in the DevelopingWorld• Email• doctortvrao@gmail.com5/29/2013 Dr.T.V.Rao MD @ health care 69