Some guidelines apply regardless of the format of documentation used. The following tips will help you ensure that your cases can be defended in the courtroom. We live in a culture of measurement. Actions, observations and intentions can be examined and compared to desired standards. In order to cope with internal and external pressures, records must be generated, stored and maintained. Medical documentation has become as important a part of health care as the implementation of practical and direct personal interventions. Refreshing our knowledge of the premises and documentation processes is essential to improve our professional technical skills. The legal issues that may arise are as follows (11): The majority of medical malpractice cases are primarily directed against the physician and the institution. However, anyone who has entered a patient`s medical record may be invited to participate in court proceedings. The purpose of this course is to educate healthcare professionals on medical record documentation requirements and professional and responsible documentation strategies.
However, 180 of them, or about 60% of them, had payments to the injured patient that exceeded $50,000 (14). However, nearly 15,000 adverse reaction reports against nurses were filed, which is more than the number of reports filed against physicians, NPs and PAs combined. Finally, you will fully understand the documentation and litigation of care and change the way you think about your practice. And if you`re ever called to court, this comprehensive guide will prepare you for what to expect next. Given the plethora of information sources that exist in the data-rich healthcare environment, it is important to define the exact elements that make up the legal health record. Guidelines from AHIMA, the American Health Information Management Association, suggest that each organization is responsible for defining the content of the statutory health record based on the capabilities of its system and legal environment (Bartschat et al., 2018). The medical record is essential for nursing documentation for several reasons. The main purpose of the medical record is that it allows members of the health team to review and analyze the data to ensure appropriate care. It allows doctors to keep track of all treatments that have already been completed for the patient. It also provides the patient with a record of the treatment they received as part of their lifetime medical history. The medical record is used to code and create an invoice for the services the patient has received. Medical records can also be used to review research processes and purposes.
Ultimately, it is also a legal document that can be used in court if necessary. Make sure the “right” person creates the documentation. For example, the Joint Board requires that the initial assessment and care plan be completed and documented by a registered nurse. Documentation by the right person is especially important in education, nutrition and rehabilitation assessments. For once, mapping has the potential to be a great asset for the documentation of electronic health records. The use of rapidly assessed checklists documenting routine business complements computer-assisted data entry at the bedside. By shifting the focus from descriptive discursive narrative paragraphs for each routine and expected event to minimal narrative notes for unexpected or highly significant events only, the CSE may be the most recent medical literature (Woten et al., 2017). Each health care facility must have a compliance system capable of managing and ensuring the accuracy and completeness of records (e.g., documentation), record keeping, and destruction of records (where applicable).
The American Health Care Association (AHCA) provides guidance to facilities on how to design compliance programs. In their recommendations for record keeping and retention, the AHCA and AHIMA list the need for any health care facility to consider the following points (Diamond, 2019). Keep the purpose of the documentation. Do not represent opinions or assumptions. Instead of writing, “The patient did not respond,” your notes should report what you saw through objective judgment. Document what you see, hear, or smell. Avoid entries like maybe, maybe, or I think. Healthcare institutions are engaged by organizations such as the Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS) to effectively manage the collection of health information using unified records and policies that guide the creation and processing of records. While the components of health records may differ somewhat from institution to institution, some minimum standards for paper and electronic documentation systems are expected (TJC, 2019).
The main goal of preventing legal complications in clinical pathways is to understand how your institution uses them and what supporting documents are required. In some contexts, the pathway has replaced the traditional care plan and progress notes with documentation created directly on the pathway document, unless the patient does not achieve the outcome. At this point, a narrative note is made. There are approximately 2.9 million registered nurses operating in the United States, of which approximately 1.6 million work in hospitals (1). Nurses in a medical unit typically spend about one-third of their total working time documenting (2). Considering that a nurse on a Med-Surg floor spends about 2.5 hours per shift on records, this translates to about 7 billion hours spent each year creating nursing documentation. And that`s just for nurses! This introductory course aims to describe the legal foundations of nursing practice. The main objective is to provide the learner with the fundamental knowledge of relevant legal concepts common in healthcare and an understanding of their implications for clinical practice.
Rachel Henderson, PhD, MS, LHRM, CCRN-K, has nearly three decades of clinical, management and consulting experience. Rachel is a Registered Legal Nurse Consultant (CCL), a Certified Health Care Risk Manager (LHRM) and a Registered Forensic Nurse (FNC). As a legal nurse consultant, Rachel works with lawyers, law firms and healthcare organizations to review and evaluate medical records to ensure they comply with standards of care and regulations of accrediting bodies, including the Joint Commission. In addition to her legal knowledge, Rachel has extensive clinical experience, including work in critical care, kidney transplantation, dialysis and surgery. Click here for more information about Rachel Henderson Remember the basics of HIPAA training related to electronic medical records. This course provides nurses with information on the value of laws and standards for nursing documentation, the legal basis for proper documentation, and techniques for documenting changes in a patient`s condition.
