Documentation in Order to Manage Risks: Part II

  • By: VALA
  • On: 11/13/2020 08:59:14
  • In: Law
  • Comments: 0
The following article is about the necessity of documentation of care provided, regardless of practice setting.

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Elizabeth E. Hogue, Esq.
(877) 871-4062
The burden of proving that appropriate services were rendered rests with providers. Staff members are especially vulnerable to claims of inappropriate care when it comes to patient falls. The key to avoidance of this type of liability is evidence of adequate precautions by staff to prevent falls. 
In Burks v. Christ Hospital [19 Ohio St. 2d 128, N.W. 2d 829 (1969)] for example, an obese patient in severe pain who was sedated to the point of disorientation was placed in a bed without side rails. The patient fell out of bed. The decisive fact for the court in this case was that the provider had no nursing policies and procedures that outlined appropriate precautions to be taken by staff to prevent liability. The court clearly wanted to see written policies and procedures regarding prevention of patient falls and documentation in patients' charts that staff followed their own internal policies and procedures.
The “good news” concerning falls, however, is that sometimes patients fall, and practitioners are not liable, in large part due to effective documentation. Killgore v. Argonaut-Southwest Insurance Company [216 So. 2d 108 (La. App. 1968)] is an example of such a case. In this case, there was clear documentation that the patient was alert and able to call for assistance. Documentation also established that the patient was placed in bed by staff and that the guardrails were in an upright position. The patient fell when she apparently attempted to climb over the rails to get out of bed. The court rejected the patient's suit in this case.  Because of the detailed documentation in this case, the only basis for her suit was that nurses had an obligation to watch her continuously, a contention that was decisively rejected.
Finally, practitioners certainly recognize that their documentation sometimes fails to meet required standards. Staff members responsible for quality assurance performance improvement (QAPI) and compliance activities are especially conscious of deficiencies in documentation. In view of possible allegations of fraud and/or abuse and loss of reimbursement, the temptation is to fix the documentation after the fact. It is not uncommon for staff members to approach other personnel to ask them to “repair” documentation. The temptation to do so without clear evidence of the circumstances under which corrections were made is too great for some staff members.
Providers are reminded that the following rules regarding documentation apply:
  1. Corrected documentation may be added to the record, but it must be dated with the time that the correction was written, not when the original documentation was written.
  2. Erasures and “white out” may not be used in patient's charts to correct incomplete or inaccurate documentation of patient care.
  3. Staff may correct documentation “after the fact” only if they actually remember the supplemental information they provide or have specific notes to jog their memories. Documentation after the fact of “normal” findings, is, therefore, often suspect. It is incredible to think, for example, that a staff member remembers a patient's normal blood pressure reading three weeks after it was taken. Supplemental documentation of abnormal findings or unusual events has more credibility, especially when the findings or events are extremely abnormal.
  4. Pressure on staff members to supplement documentation outside of these rules is inappropriate.
Supervisors constantly “harp” on the importance of complete, accurate, contemporaneous documentation. Staff members may tune out at this point because they have heard the same admonitions many times. The fact is, however, that documentation is one of few sources of evidence of quality of care. In short, good documentation is often the hallmark of good care and is essential for the avoidance of allegations of fraud and abuse.
©2020 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.


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