(1) primary communication tool; essential for good patient care

-the chart illustrates what each member of the team needs to know to continue care

-provides basis for the bill and insurance payment

-med chart is the first item requested in a claim (the witness that never lies and never dies)

(2) the patient record and risk reduction

-routine care should be charted (chief complaint; subjective and objective findings; diagnosis; treatment plans; response to treatments)

-condition changes should be charted (with corresponding actions

-chart describe how complications were managed

(3) The chart should defend care

-Were meds give?

-what was the overall condition of patient?

-did the patient respond to treatment?

-were there lapses in care?

-was there inappropriate care or failure to provide care (turning patient)?

_was the team consistent? were there discrepancies among the disciplines?

(4) utilization and financial record

-the chart is a utilization record(resources used in care, who saw and participated with patient, chart reflect need for care given)

-chart a record to substantiate a financial picture (services used, procedures and meds, level of care)

-if questioned, this is the audit tool that will be judged. may be basis for a fraud claim

(5) the role of policies and procedures on documentation

-illustrate hospital philosophy and standards

-jcaho requirements, state and hcfa regulations

-standard of care for vital activities: assessment and reassessment

-ensure consistency

-Contain WHO, WHAT, WHEN, WHERE

-Factual, Objective Notations (avoid "appears to be" "inadvertently" and "unfortunately"

-Being Specific

-Timely notes (time and date, electronic monitors, late entries)

-Not tampering

-Leaving no blank lines

-Legible

-Accurate

-Discharge Documentation

(1) Nurse-Physician calls

-Cover who, why, when, where they contacted, and what was reported

(2) Record discussion of patient's condition

-repeat all orders back w/o abbreviations

(3) communicating with office staff or answering services

-Document....name of person and service called, message you left, whether you indicated it was urgent, date and time of call, plan, and the TIME the return call was received

-call again if no response, time interval depends on how significant the information

-the patient care record demonstrates compliance

-goals...prevent false or inaccurate claims, minimizing loss to gov't, identify unethical and criminal conduct, provide method for corrective action

• use quotes when possible to illustrate the non compliant behavior
• document what instruction wasn't followed
• don't label patient
• note who you informed about behavior
• document all incidences
• document what you tell patients at follow-ups, aware of consequences of not taking medication,and be clear about what you discusssed and what patient stated to you if they left against medical advice

*informed refusal is different that non-compliance

It is the responsibility of dependent professionals is to communicate information to those who can intervene (licensed indep. practitioners)

-primary areas of liability for dep professionals is failure to keep physician informed of patients condition and failure to carry out orders in a timely and accurate fashion

Document what info you shared

• tell patients story
• make it objective, factual and complete
• date and time the entry
• date and time the event that occurred
• note source of into (lab, test results, and observations)

if the condition requires you to notify another practitioner document this as part of your action plan (do what you state you will and do not criticize another providers care in your notes)

• tell patients story about the event even though an error's involved
• describe the convo with patient or family
• notes free from speculation and conclusions (don't put a spin on it)
• avoid subjective commentary
• no self serving comments to justify your actionw
• don't state report is complete
• don't write you disagree with someone; write the details you know
• correct correctly (single line, initials, error, date)