Documentation for Medicolegal Purposes

1. Documentation for Medicolegal Purposes Elizabeth Barrall Werley, MD Program Director, Assistant Professor of Emergency Medicine Penn State Health

2. Malpractice Information Leading causes of error Errors in diagnosis (37%) Procedural complication (17%) Leading diagnoses involved in claims Acute MI Fractures Appendicitis

3. Malpractice Information Missed diagnosis = frequent cause of error ($$$) No/limited DDx Error in testing (delay or incorrect test) Premature discharge/inadequate assessment Undiagnosed condition >> incorrect diagnosis

4. Malpractice Information Breakdown in communication between nurse and physician Change in patient condition Change in vital signs Change in response to treatment

5. Where Does Error Come From? ED = #3 healthcare site for errors Risk of harm in ED disproportionate

6. Where Does Error Come From? 22% diagnostic studies 16% administrative procedures 16% pharmacotherapy 13% documentation 12% communication 11% environmental 9% other

7. When Errors Occur Disclose and apologize Collaborate with patients Shared decision making Seek feedback Assume some errors are a given  anticipate and search

8. When Errors Occur Transitions of Care Errors: documented information differs from verbal hand-off Omission: relevant information documented but not included in hand-off Longer hand-off  increased exam errors Longer length of stay  increased likelihood of omissions Fewer errors and omissions with EMR/notes for hand-off

9. When Errors Occur Charting errors, incomplete charts Chart audits Contemporaneous with live documentation and discharge

10. When Errors Occur Dictation/Voice Recognition Better than scribe? Dictation errors Almost 15% were critical errors Annunciation errors Deletions Added words Also: nonsense errors, homonyms, spelling errors

11. Why We Document Communication to other providers – continuity of care Preservation of information Billing and reimbursement Medicolegal protection Quality assurance/improvement reviews Clinical data collection/research

12. Electronic Medical Record The EMR alone can contribute to error Communication failure Wrong order – wrong patient Multiple unidentified patients Poor data display Alert fatigue

13. Electronic Medical Record Make your EMR work for you Improve appearance of data If possible…

14. Electronic Medical Record Free text vs complaint-driven templates “Quicksheets” existed in paper format prior to electronic records Comprehensive yet efficient May incorporate clinical decision tools, protocols, etc.

15. Electronic Medical Record Clinical guidelines incorporated into EMR software Trialed for three complaints: low back pain, pediatric fever, blood/body fluid exposure Improved documentation Improved patient care Improved patient satisfaction

16. Electronic Medical Record The “chart dive” Discharge summaries Previous testing Benefits to patient care Drawbacks

17. Electronic Medical Record Improve efficiency Voice recognition software (dictation) Templates Scribes Text expansion

18. Electronic Medical Record AAEM Position Statement on Medical Scribes Consider ancillary staff Duties “should not include independent interaction with a patient, order entry or selection of discharge plans or documents.”

19. Documentation Use of clinical guidelines in documentation can be protective Reflect standard of care Watch for bias, contradiction Must be based on current EBM May increase liability if guidelines not followed Guide shared decision making

20. Documentation Incorporate QI/Risk Management Documentation incorporated into employee orientation Standardized documentation Prompts/risk reminders Chart audits

21. Tips/Tricks Chart Flow – should read like a story Beginning Evolution Conclusion Future

22. Tips/Tricks Teaching documentation Accurate and complete  concise Organization Concise

23. Tips/Tricks Teaching documentation Subjective – chronologic, lay terminology, patient quotes Objective – medical terminology, no quotes Be specific in physical exam Interpret labs, imaging

24. Tips/Tricks Teaching documentation Assessment/medical decision making Differential diagnosis Plan Disposition

25. Tips/Tricks Medical Decision Making DDx What you’re testing for/not Why Location EMR-dependent

26. Tips/Tricks - Musts “If it isn’t documented, it didn’t happen.” Review registration data Review nursing notes/assessments – address discrepancies Review EMS notes (when available) – address discrepancies Additional information obtained later

27. Tips/Tricks - Musts Date/time stamp – don’t rely on EMR Legibility (if not typed) Focused but thorough history and exam Vital Signs: abnormalities Results of all diagnostic tests Response to therapy Serial exams

28. Tips/Tricks - Musts Consultant with name, time of conversation, recommendations Medical decision making Procedures Discharge planning/follow-up AMA

29. Tips/Tricks - Nevers Nothing derogatory Never change a signed note Write an addendum, data/time No “chart wars”

30. Tips/Tricks Teaching documentation Assessment/medical decision making Differential diagnosis Plan Disposition

31. Tips/Tricks Macros/templates Risk if pre-checked portion doesn’t match patient encounter Least info in each macro Build multiple choices Combination of template + free text

32. Tips/Tricks Quality and safety measures Alerts IT logic Default orders Prompts Decision support tools Standardize care/minimize options

33. Tips/Tricks Date/time stamps Absolutely critical Documentation often occurs after care Provide chronological flow – especially important if case progresses or changes

34. Tips/Tricks Transitions of care (EDED) Standardize the process Timing Information exchanged Change in plan/change in status

35. Tips/Tricks Transitions of care (EDadmission) Time Who/service Information exchanged Time set for evaluation

36. Tips/Tricks Discharge Relevant findings Incidental findings Diagnosis Follow-up Return precautions

37. Tips/Tricks Discharge Abnormal vital signs PO challenge Very old Very young Ambulate/”road test”

38. Additional Risks Metadata Simultaneous charting Incidental findings AMA

39. Top Ten Documentation Mistakes ACEP→Practice→Ethics & Legal→Top Ten Documentation Mistakes