DOCUMENTATION:

WORST ENEMY OR BEST FRIEND??

This Photo by Unknown Author is licensed under CC BY-SA

It can be both!

The trick…is to STOP thinking about it like this:

OR…Like this …

And start thinking about it like this:

What we are going to talk about today: General Information Narratives in the EMR Patient advocacy EMTALA documentation Incident reporting Verbal orders/read backs Post-medication assessments Audit trails Copy forwards

The Parthenon was created circa 495 BC.

How has it lasted so long ?Solid foundationBuilt well

The Parthenon was created circa 495 BC.

Why important today?Withstood the test of timeHistorical – reminds us of

what occurred

Your charting:

Foundation for patient care Your memory/history of

patient care

You are taking care of patients

EMRs often seem as though they were designed by a committee of lawyers

And you may question the need for the extensive documentation you are asked to maintain

But often when a claim is brought it is years after the actual event and memories can be fuzzy or even non-existent

… baby claims can be 8 years later

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Records are ALWAYS an important part of patient care and are your memory

But they are CRITICAL when the provider has little/no recollection of the patient/care

Narratives in the EMR

EMR = fall into the routine of check boxes But check boxes don’t tell “THE STORY” EMR template canNOT capture all info EMR ALLOWS for narratives Narratives capture IMPORTANT info Narratives SHOW YOU CARED FOR THE PATIENT BUT they must be ACCURATE

Accuracy in Narratives

“Presents with right pinky finger pain. He sexually has pain and a mild deformity there.”

“Vital signs: Last 24 hours: No vital signs available.” “Patient 5 years of age.” (75-year old patient) “52 year old female” (patient is male) “Pt had a collision at an 8 hole with another car.”

Patient advocacy and documentation

What is patient advocacy?

Patient advocacy and documentation

1. Steps to be taken (chain of command) Talk to nursing supervisor Talk to unit manager Talk to house supervisor Talk to physician

2. Why document? Shows process Shows your work to be a patient advocate

EMTALA and documentation

The Emergency Medical Treatment and Labor Act is a statute which governs when and how a patient must be: (1) examined and offered treatment or (2) transferred from one hospital to another when he is in an unstable medical condition.

The avowed purpose of the statute is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to "charity hospitals" or "county hospitals" because they are unable to pay or are covered under the Medicare or Medicaid programs.

EMTALA Duties

In essence, then, the statute: imposes an affirmative obligation on the part of the

hospital to provide a medical screening examination to determine whether an "emergency medical condition" exists;

imposes restrictions on transfers of persons who exhibit an "emergency medical condition" or are in labor, which restrictions may or may not be limited to transfers made for economic reasons;

imposes an affirmative duty to institute treatment if an "emergency medical condition" does exist.

Example

Incident Reporting

Reporting Of an incidentIn a protected environment

Incident Reporting

*Allow for improvement patient care/work environment

*By allowing for reporting of incidents*Without fear of repercussion*And to start the process of

review/investigation

Just as there are certain things you should document in the patient chart, there are others which perhaps you should not…

Incident Reporting

* Equipment issues* Patient care issues

- Policy not followed- Poor outcome (ie falls)

* Personnel issues- Disruptive behavior- Inappropriate behavior

Important to remember, not only are other providers looking at your patient care records, one day it’s possible…

…THE PATIENT, THEIR ATTORNEY, A JUDGE AND JURY MAY BE LOOKING AT THOSE RECORDS.

Examples – For incident report versus patient record:

Fetal heart monitor No. 14 malfunctioned Realized during OR cleaning sterilization button not activated Patient assessed as fall risk, but fall precautions not implemented Dr. B yelled obscenities at nursing staff, in front of patient, as follows: Fall: Have to put fact of fall and details relevant to care in the patient chart,

but there may be incidentals it would be important for risk management to know that do not directly deal with patient care (egs: this is third time patient under this nurse’s care has been found on floor with oxygen tubing wrapped around legs)

Verbal orders / read backs

Check policy If you receive a verbal order, and are required by

policy to read back…. … then document as follows:

1. Write order 2. Read order word for word back to provider3. Document: “Order recorded and read back to

provider as recorded”

Post medication assessments

Review policyFollow policyDocument, document, document

1. Medication given2. Follow policy time frame/required assessment3. Document even if no change in patient4. To show you checked5. Use narrative if need to

Audit trails

Every time you are in the chart, you leave a footprint Patient’s attorneys are becoming more and more aware

of this and are pushing for hospitals to turn over audit trails

They show changes to the chart after the fact They show who viewed the chart They show HIPPA violations

Examples

Copy Forwards

Looks like you did not assess

Makes you look lazy/sloppy

Can result in cross outs when viewed / printed

Examples