Neurological

5 best practices for medical documentation

I am a family nurse and have also been involved in life planning for a number of years. At its core, this is about planning the need for care and the associated costs in connection with a catastrophic injury or chronic illness. My job has been in the legal field and has involved reading thousands of pages of medical records and statements. In the course of this work, some clear patterns in the documentation or lack thereof have emerged. As clinicians, we know what and how to document in medical records; in practice, however, it is not documented consistently enough.

In addition to being asked to adhere to best practices for reasons of form and appropriateness, vendors should keep in mind that there is always the possibility of being asked to give testimony or even a lawsuit. Should any of your patients file a personal injury or malpractice lawsuit, regardless of whether the lawsuit is related to your treatment, you can be withdrawn and your clinical records will take on a whole new meaning. Below are 5 tips on documentation best practices.

1. Document your exam

Failure to document a physical exam is the most common mistake I see. We may overlook this step if we are documenting hours or possibly days after seeing the patient or forgetting to change the default electronic medical record (EMR) setting. Either way, failure to document your physical exam results can be your downfall. I have read statements from several vendors who failed to document the test they are certain they ran. The obvious question from a lawyer is, “If you forgot to document your exam, what else did you forget?” It opens the window for great doubts about the credibility of the provider.

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2. Know what information is prepopulated in your electronic medical record

Using an EMR template is helpful and quick, but you need to know what is pre-assigned in the note and remember to make any patient-specific changes. If your template automatically includes Normal Checks Detailing and System Element Checks (ROS), even if you include alternative results at the end of the check or in paragraph form, you will need to deactivate, delete, or modify parts of the check in the template applicable to the Main complaint was abnormal or irrelevant. The results must be consistent across your note. Leaving the original normal entry if it contradicts the main complaint, the examination findings, or the assessment and treatment plan leaves room for questions and doubts.

3. Be careful with copying notes from previous visits

While the ability to copy the last visit note is helpful in documenting visits for patients with chronic problems, it is important to read the updated note. What can often be a useful time saver can become a burden if forgetting to update the old note calls its accuracy into question. Copying notes often results in inaccurate timeframes for problems or illnesses being recorded, symptoms or physical exam documentation being incorrectly verified, or a plan becoming inapplicable. Don’t leave the question unanswered as to whether you actually re-prescribed an acute or controlled drug, or why you didn’t update your plan based on new information.

4th Document communication outside of visits

When you send a patient a letter with their results, call them to discuss a finding, return a call with a question, or have some other form of communication outside of an office visit, make sure the interaction is documented or copied to their patient record will. Make sure your support staff is following the same protocol. It is so easy to forget or leave small conversations without documentation; However, in the event of a withdrawal, it is critical to be able to demonstrate that you have not ignored a patient and communicated with them effectively.

5. Write down future plans

We often don’t think about who reads our notes after we sign them. When medical care is rescheduled, life planners, social workers, medical specialists and other service providers need this information in order to plan and coordinate care. Clinicians often know what steps they will take for the next patient follow-up visit, and documenting this plan can be extremely valuable during care transitions. Examples of such documentation are “1 month follow-up for a change in losartan dosage and then resume routine follow-up every 3 months” or “We will start sitagliptin for diabetes today and discuss with the patient that insulin treatment may be required when it does “not effective.”

The bottom line is that most of us provide excellent care to our patients and we need to make sure that is reflected in our records. A lawsuit relating to any aspect of a patient’s health can put your records to the test – make sure they last!

Lisa Gay, MSN, RN, FNP-BC, CLCP, is a family nurse at Plessen Healthcare in St. Croix and a certified Life Care Planner at Case in Point, LCP, based in Florida.

The author would like to thank you Keeli Frickswho provided general editing services and helped with the clarity of the content of this article.

This article originally appeared on Clinical Advisor

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