III. Pearls: Approach

  1. Be accurate
    1. Review canned phrases (boilerplate, macros) in electronic records
    2. Avoid copying and pasting sections from another of the patient's encounters
      1. If used, copied sentences should be denoted in quotes and referenced to the source of the quote
      2. Copying propogates medical errors and artificially increases encounter coding
      3. Centers for Medicare and Medicaid Services (CMS) sees copying/cloning records as fraud
    3. Do not blindly insert text for history or exam elements that were not completed
      1. Example: PERRLA includes accommodation, which is often documented, but not actually tested
    4. Never alter or edit prior records
  2. Be complete
    1. Lawyers mantra: "not charted, not done"
    2. Review nursing notes and Vital Signs (and address differences in real time)
    3. Record interval progress notes with time stamps
      1. Interval of at least hourly (more often for more serious presentations)
      2. Targeted update based on results, changing signs and symptoms, and response to interventions
    4. Avoid time delays in documentation
      1. Late entries should be time stamped
    5. Medical decision making
      1. Documenting a coherent Thought Process is among the most important parts of the medical record
  3. Be consistent
    1. Always confirm you have opened the correct patient record first (before review, writing orders, medical decision making)
    2. Last Line of plan (and do this with every patient)
      1. Assessment and plan reviewed with patients
      2. Patients questions answered
  4. Be objective
    1. Do not write what you would not want the patient to read
      1. Avoid disrespectful comments in the medical record
    2. Do not criticize in the medical record
      1. A patient's negative comments about prior care (if medically relevant) should be in quotations
  5. Be legible
    1. Avoid confusing abbreviations
    2. Correct errors on paper correctly
      1. Errors in a paper record should be corrected with a single strike-through line, with initials and date

IV. Pearls: Do not put non-relevant, discoverable information in record

  1. Do not speculate on cause of a complication
    1. Example: Perinatal asphyxia causing Cerebral Palsy
  2. Do not admit guilt or blame in the medical record
  3. Avoid non-neutral phrases in text (e.g. mistake)
  4. Do not document legal Consultation in record
  5. Do not put incident reports or reference to such reports in the medical record
  6. Do not document conflicts between clinical or administrative staff in the medical record
  7. Avoid putting disclaimers in the record (e.g. "excuse inaccuracies due to ...")

V. References

  1. Henry (2013) Avoid Being Sued, EM Bootcamp, CEME

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Ontology: Documentation (C0920316)

Definition (MSH) Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information.
Concepts Intellectual Product (T170)
MSH D004282
LNC LA17600-0
English Documentation, Documentations, documentations, documentation
Swedish Dokumentation
Czech dokumentace
Finnish Dokumentaatio
Russian DOKUMENTATSIIA, MEDITSINSKAIA DOKUMENTATSIIA, ДОКУМЕНТАЦИЯ, МЕДИЦИНСКАЯ ДОКУМЕНТАЦИЯ
Croatian DOKUMENTACIJA
Polish Dokumentacja naukowa, Informacja naukowa
Norwegian Dokumentasjon
French Documentation
German Dokumentation
Italian Documentazione
Dutch Documentatie
Portuguese Documentação
Spanish Documentación

Ontology: Clinical report documentation (C1315014)

Concepts Intellectual Product (T170)
LNC LP32519-8, MTHU000054
English Clinical report documentation, DOC.CLINRPT

Ontology: Patient Documentation (C2368630)

Concepts Health Care Activity (T058)
English Patient Documentation