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Tips on How to Protect Your Agency Document Everything

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court. Earlier this year, a home care nurse was called to testify in a trial involving a medication she gave to her patient four years ago. During that time, she cared for hundreds of patients and provided thousands of visits. Without factual and accurate documentation, it would have been difficult to recall exactly what happened four months ago, let alone four years ago. Fortunately, her documentation was very specific and was a large factor in the dismissal of the case.
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More or less a patient can wait several years to file a lawsuit and then it can take months or even years before the suit goes to court. One story worth sharing was a home nurse was called to testify in a trial involving a medication she gave to her patient four years ago. Without proper and accurate documentation it would have been difficult to recall exactly what happened months ago, let alone four years ago as she has cared for hundreds of patients and provided thousands of visits. Fortunately, her documentation was very specific and was a large factor in the dismissal of the case.

Nine Ways to Protect Your Agency

Accurate Documentation – Agency policies should define how soon after the visit the documentation must be recorded. Agencies that allow staff to document their activities at the end of the day when they are tired and in a hurry (or at the end of the week to “catch up” on documentation) risk ending up with inaccurate notes. The closer the documentation is recorded to the actual event, the more reliable it is.

Factual Documentation- Agency staff should state the facts by using objective, not subjective, terms. Advise staff to record their senses (touch, feel, and smell), the patient’s actual words, and use specific measurements.

Complete Documentation – Look to industry standards of practice to identify comprehensive documentation. Avoid the use of vague terms like “raw” wound, “healing well,” “small,” “moderate,” or “large” amount of drainage, and use objective terms. For example, staff should document the specific length, width, and depth of the wound (“9x5x1cm”) or, for a small wound, compare it to a common object (“size of a dime”). Drainage could be documented as “saturates 2 4x4s in a 24-hour period.

Abbreviations- Use only agency-approved abbreviations and conform them to generally accepted lists.

Unsolved Mysteries- . Describe gaps in service caused by missed visits or hospitalizations. Document communication with physicians or other clinicians related to new findings or changes in the patient’s condition.

Criticism- In most states, patients have the right to review their clinical records; therefore, staff must be careful about what they document. Incidents reports should be documented according to agency policy and is separate from the clinical record. Document what you did for your patient within your shift and avoid criticizing other staff in your clinical documentation.

Corrections and Late Entries- When correcting your entry you should simply draw a line across the incorrect entry and note your initials and put the date. No one is allowed to use correction liquids or eraser.

Coordination of Care – Documentation should reflect all attempts to contact the physician regarding changes in a patient’s condition. Include the name of the physician notified, a brief summary of the reason for the call, and the physician’s response.

Overall, a medical record should be an organized and clearly written synopsis of a patient’s course of care from admission through discharge. A factual, complete, and timely documentation, the medical record paints the full picture for the reader.