Documentation: A Primer on Charting in the Medical Record

December 31, 2019 | Aging Services Risk, Quality, & Safety Guidance

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Poor communication is an enduring source of resident safety incidents. Even a well-trained clinician will make mistakes if he or she is working from inaccurate or incomplete information. Poor documentation is also a potential source of liability for an institution or a provider; in a medical malpractice case, it is rare to find documentation that fully supports the care provided. The medical record is also a legal document that must be completed correctly. Attempts to mislead readers of the medical record can lead to significant civil and criminal liability. If a medical record is inappropriately modified, amended, or destroyed—even if the care was appropriate—it may undermine the possibility of defending a medical malpractice claim.

Documentation skills are learned, and documentation is complex and highly variable. Much knowledge of how to document is anecdotal; providers pass on knowledge they gained after documenting improperly and being called to task for their errors. Additionally, many people develop their own style of documentation, which can result in inconsistencies in the medical record.

Much of communication is nonverbal, and cues such as tone of voice, inflection, emphasis on certain words, and physical gestures can all give different meanings to words. These cues are lost in written communication, such as charting in a medical record. By the same token, if the writer vents frustration at the care given by another provider, the message will be exaggerated by the lack of context. "Venting" in the medical record, including criticizing the resident or another provider, should always be avoided. Unless the writer can accept that another provider, the resident and family, and, potentially, a jury will view and interpret the entry, refraining from such comments is best.

Clinicians sometimes believe that they will retain a "flashbulb" memory of an event—a recollection that will not fade with the passage of time. Sometimes this is true (if the event was stressful, dramatic, or exciting), but most times it is not. For example, a clinician will not remember all the details of care for a surgical patient who develops a surgical wound infection days or weeks after discharge. Anecdotally, many medical malpractice claims have been brought in which the first notice of the problem...

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