Chapter 8
DOCUMENTATION
Importance of Documentation
• Provides for the following:
– A written record of the incident
– A legal record of the incident
– Professionalism
– Medical audit
– Quality improvement
– Billing and administration
– Data collection
Why to keep records?
• Helps in medical decisions
Helps to share responsibility with the patient
• All reputed Hospitals Keep Your Documents for
several decades.
Legal obligation
• Protects the patient as well as doctor in front of the court
Legal Aspects of Charting
• Be accurate about time & chart as soon as
possible after an event
• Document omissions (med not given or
treatment not completed) & reason & actions
taken
• Do not leave blank spaces
• Record legibly & in black ballpoint pen
Legal Aspects of Charting
• Do not erase, use white-out, or scribble out errors
• Do not write retaliatory or critical comments; do not place
blame on your colleagues
• Correct all errors promptly
• Spell correctly
• Record all facts in objective terms
Court Believes your Documents only
• Document completely (in court - if it's not
documented, it wasn't done)
Correct your Mistakes with Sense and
Legality
• Never use whitener
• Never scratch out
• Draw a line through the mistake
• Initial above the mistake
Rules in keeping medical records as it
requires Confidentiality
1.
Personal biographical data include the address,
employer, home and 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, unique electronic identifier or
initials.
3.
All entries are dated.
Rules..Contd...
3. The record is legible to someone other than
the writer.
4. Significant illnesses and medical conditions
are indicated on the problem list.
5. Medication allergies and adverse reactions
are prominently noted in the record.
Types of Medical Records
Elements of Good Documentation
•
•
•
•
•
•
Accuracy
Legibility
Timeliness
Unaltered
Professionalism
Completeness
Professionalism
• Never include slang, biased statements, or
irrelevant opinions.
• Include only objective information.
• Always write and speak clearly.
Narrative Writing
• Subjective part of your narrative comprises
any information you elicit during your
patient’s history.
• Objective part of your narrative usually
includes your general impression and any data
you derive through inspection, palpation,
auscultation, percussion, and diagnostic
testing.
Two Narrative Formats
• CHART
– Chief complaint
– History
SOAP
Subjective
Objective
– Assessment
– Rx (treatment)
– Transport
Assessment
Plan
Triage tags are used to record vital
information on each patient quickly.
Medical Billing and Coding Needs
Documentation
• Without adequate medical documentation, your
health care providers might not be reimbursed
for providing you with care, leaving you stuck
with the bill.
• There's an old saying in the health care industry:
"If it's not documented, it didn't happen.
Consequences of
Inappropriate Documentation
• Inappropriate documentation can have both medical
and legal consequences.
– Do not guess about your patient’s problems.
– Write neatly, clearly, and legibly.
– Complete your form completely.
– Spelling counts!
Excellence in Medical Documentation
Reduces Malpractice Allegations
• Excellence in medical documentation reflects and
creates excellence in medical care.
• At its best, the medical record forms a clear and
complete plan that legibly communicates pertinent
information, credits competent care.
• Forms a tight defense against allegations of malpractice
by aligning patient and provider expectations.