DOCUMENTATION: WORST ENEMY OR BEST FRIEND??

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1 DOCUMENTATION: WORST ENEMY OR BEST FRIEND?? This Photo by Unknown Author is licensed under CC BY-SA

2 It can be both!

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

4 OR Like this

5 And start thinking about it like this:

6 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

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8 The Parthenon was created circa 495 BC. How has it lasted so long? Solid foundation Built well

9 The Parthenon was created circa 495 BC. Why important today? Withstood the test of time Historical reminds us of what occurred

10 Your charting: Foundation for patient care Your memory/history of patient care

11 You are taking care of patients

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

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

14 But often when a claim is brought it is years after the actual event and memories can be fuzzy or even n non-existent baby claims can be 8 years later

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

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

17 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

18 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.

19 Patient advocacy and documentation What is patient advocacy?

20 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

21 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.

22 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.

23 Example

24 Incident Reporting Reporting Of an incident In a protected environment

25 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

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

27 Incident Reporting * Equipment issues * Patient care issues - Policy not followed - Poor outcome (ie falls) * Personnel issues - Disruptive behavior - Inappropriate behavior

28 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.

29 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)

30 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 provider 3. Document: Order recorded and read back to provider as recorded

31 Post medication assessments Review policy Follow policy Document, document, document 1. Medication given 2. Follow policy time frame/required assessment 3. Document even if no change in patient 4. To show you checked 5. Use narrative if need to

32 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

33 Examples

34 Copy Forwards Looks like you did not assess Makes you look lazy/sloppy Can result in cross outs when viewed / printed

35 Examples

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