Documentation

1. Documentation A Lawyers Perspective

2. Medical Records Are Critical • Influence & Shape Claim or Litigation • Are the Foundation of Your Defense

3. Statute of limitations: 2 years Service: 1 year Non-suit: 6 months Re-Serve: 1 year Children 10th Birthday Timeline of a Lawsuit

4. Records That Influenced Litigation

6. The Pre-Printed Order Sheet The Handwritten Orders The Daily Order Summary

8. The Electronic Medical Record “A Whole New Pasture”

9. The Essentials T-N-N • Think • Navigate • Narrate

10. Think • Don’t Get Complacent • Critical Thinking • Evaluate • Formulate Differential Diagnosis

11. NAVIGATE • There is More to the Record than Flow Sheets and Progress Notes • Know Where to Put Information • Know Where to Find Information

12. NARRATE • Flow Sheets/Data Fields Provide Basic Information • Must Write Notes • CANNOT Chart Just Using Flow Sheets/Data Fields • CANNOT Systematically Check Boxes

14. General Do’s • Make Entries • Make Timely Entries • Accurately Time Your Entries • The EMR creates an electronic footprint • 3 time entries will be available on/in record • Not Everything Happens on the Hour • Be aware of meta-data • Review of x-rays and lab data • Be objective • Be specific

16. THE BIG ONE ! • Document Conversations with Patients • Document Conversations with Staff • When and Why You Were Called/Paged • What About Patients Condition Reported • What Orders/Instructions Did You Provide

17. THINGS NOT TO DO ! • Cut and Paste

18. Dietary recall is not appropriate for recommended 1800 calorie 3 meal-3 snack ADA diet. She is missing too many snacks, is not eating enough vegetables, is making food choices that are too high in fat and is not always adhering to the recommended schedule for meals and snacks. At this time she is managing her diabetes with diet only.

19. Dietary recall is not appropriate for recommended 1800 calorie 3 meal-3 snack ADA diet. She is missing too many snacks, is not eating enough vegetables, is making food choices that are too high in fat and is not always adhering to the recommended schedule for meals and snacks. At this time she is managing her diabetes with diet only.

20. Dietary recall is not appropriate for recommended 1800 calorie 3 meal-3 snack ADA diet. She is missing too many snacks, is not eating enough vegetables, is making food choices that are too high in fat and is not always adhering to the recommended schedule for meals and snacks. At this time she is managing her diabetes with diet only.

21. Patient complains of SOB, weakness and pain in upper extremities, feels like heart is jumping. Will get cardiology consult. Patient had pace maker inserted in 2001. Intact bilateral pedal pulses

22. MORE DONT’S • Do Not Overuse the Auto-Populate Feature • Don’t Debate Clinical Care in the Record • Never Chart in Advance

23. BE CAREFUL ! • Descriptive Prompts That Aren’t So Descriptive • May not adequately and completely describe patient’s condition • Drop Down Menus • Clinical Presentation • Drug Names • Dosage Amounts

25. Addenda/Deletions/Alterations Perception is Important

27. What Happens When Someone Pushes Print • The “Official” Patient Record is Not the Record that You are Familiar With

28. Is It Just Us ?

30. Use Your Resources • Medical Staff • Risk Management • EMR Committees

31. Suggested Additions

32. By: M. Todd Gerber