II. See Also
III. Pearls: Medicolegal
- Be accurate
- Review canned phrases (boilerplate, macros) in electronic records
- Avoid copying and pasting sections from another of the patient's encounters
- If used, copied sentences should be denoted in quotes and referenced to the source of the quote
- Copying propogates medical errors and artificially increases encounter coding
- Centers for Medicare and Medicaid Services (CMS) sees copying/cloning records as fraud
- Do not blindly insert text for history or exam elements that were not completed
- Example: PERRLA includes accommodation, which is often documented, but not actually tested
- Never alter or edit prior records
- Be complete
- Lawyers mantra: "not charted, not done"
- Review nursing notes and Vital Signs (and address differences in real time)
- Record interval progress notes with time stamps
- Interval of at least hourly (more often for more serious presentations)
- Targeted update based on results, changing signs and symptoms, and response to interventions
- Avoid time delays in documentation
- Late entries should be time stamped
- Medical decision making
- Documenting a coherent Thought Process is among the most important parts of the medical record
- Be consistent
- Always confirm you have opened the correct patient record first (before review, writing orders, medical decision making)
- Last Line of plan (and do this with every patient)
- Assessment and plan reviewed with patients
- Patients questions answered
- Be objective
- Do not write what you would not want the patient to read
- Avoid disrespectful comments in the medical record
- Do not criticize in the medical record
- A patient's negative comments about prior care (if medically relevant) should be in quotations
- Do not write what you would not want the patient to read
- Be legible
- Avoid confusing abbreviations
- Correct errors on paper correctly
- Errors in a paper record should be corrected with a single strike-through line, with initials and date
- Do not put non-relevant, discoverable information in record
- Do not speculate on cause of a complication
- Example: Perinatal asphyxia causing Cerebral Palsy
- Do not admit guilt or blame in the medical record
- Avoid non-neutral phrases in text (e.g. mistake)
- Do not document legal Consultation in record
- Do not put incident reports or reference to such reports in the medical record
- Do not document conflicts between clinical or administrative staff in the medical record
- Avoid putting disclaimers in the record (e.g. "excuse inaccuracies due to ...")
- Do not speculate on cause of a complication
- References
- Henry (2013) Avoid Being Sued, EM Bootcamp, CEME
IV. Management: Miscellaneous
- Patient Reported Outcome Measures (PROM, e.g. GAD-7, PHQ-9, CAGE)
- Improve diagnosis and documentation
- Improve patient-provider communication and trigger management changes
- Gibbons (2021) Cochrane Database Syst Rev (10):CD011589 [PubMed]
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| 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 |
