Mindel Scott

Legal Implications of Documentation

Records are the legal property of the veterinary clinic and/or the veterinarian who owns the practice. Patient information may only be disclosed to the client at the discretion of the attending veterinarian. The customer has the right to access all information contained in the files. Good documentation of care is patient-centered and evidence-based. By using comprehensive, clear, concise and objective documentation, the nurse has a stronger position in legal proceedings. This chapter discusses the benefits for patients and providers and provides tips for successful documentation. Can the absence or absence of certain documents be absolute proof that standards have not been met? Can we expect busy bedside doctors to record every action they take? According to Ayello et al. “Undocumented, not done, the focus is on patient care and on creating `perfect documents.`” 1 The legal implications of the literature are discussed with a focus on documenting care in the era of electronic patient records (EMRs). Strategies for clear, concise and credible documentation are described using examples.

The nurse`s role in patient safety and risk management related to EMR documentation is identified. Undocumented, not done We often encounter the phrase “undocumented, not done” in wound care court proceedings. The applicant (and lawyer) searches the spreadsheet for accurate evidence of care, as documented in the table, and presents what they consider to be absolute evidence that the facility meets the standard of care or not. What is a “standard of care”? There are many definitions, but at its core, a standard of care is what any reasonable physician would do in similar circumstances. If the standards of due diligence have been met, the defendant takes precedence; If not, the applicant does. In all legal actions involving a malpractice claim, the clinical record is considered the most credible source of information. This chapter discusses these legal considerations and examines risky documentation practices that could put a nurse at risk. Case Analysis For example, when I look at a spreadsheet for lawyers, I too look for perfect “turn Q2 hour” documentation when a patient is at risk or has an existing pressure ulcer. Perfection is rare.

And even if there is perfect documentation every two hours, how can we really know that these actions were really done, or if the employees sat down at the end of the shift and filled in their initials every two hours (i.e. created perfect items, but did not necessarily provide perfect patient care)? Poor documentation Poor documentation related to wound care, but not necessarily evidence of lack of care, can be twisting and positioning, feeding and nutritional measurements, the contact surface on which the patient was (mattresses and seats), possible refusals of care, when exactly the dressing was changed and what was used (ideally recorded each time, but often not), conversations with doctors and families, transferring patients out of bed and many more of the myriad actions bedside nurses and other health care providers perform throughout their busy day. This chapter discusses common documentation errors and harmful documentation practices. Examples of risky documentation and other documentation techniques are reviewed. This chapter also discusses the use of diagnostics by nurses and the importance of using only appropriate nursing diagnoses rather than medical diagnoses. Since the veterinary dossier is a legal document, the following principles must be strictly adhered to when writing the dossier: In the last blog, I discussed wound documentation and how it is a very necessary communication tool between wound care professionals and also as a record of the care provided. It is used by lawyers to prove whether or not due diligence standards have been met in a particular case. Wound documentation should be clear, concise, chronological, continuous and reasonably complete.1 An ambitious goal. Nursing documentation is the primary evidence that a nurse has followed nursing standards and gives the nurse credibility in cases of malpractice. This course discusses the legal implications of documentation and common errors in clinical records. Examples of erroneous graphs are verified using appropriate alternative methods to document the results.

This course also covers patient-centered documentation to support quality care. With proper and robust documentation, the nurse is better able to follow the patient`s care plan and defend against malpractice. Faculties, planners, authors and lecturers Disclosure of conflicts of interest: There is no disclosure to explain. Anthony J. Jannetti, Inc. is accredited by the Commission on Accreditation of the American Nurses Credentialing Center (ANCC-COA) as a provider of nursing education. MedBridge is committed to ensuring accessibility for all of its subscribers. If you require accommodation for people with reduced mobility, please contact [email protected]. We will process requests for reasonable accommodation and, where appropriate, take reasonable precautions in a timely and effective manner. You must be logged in and have this session to post comments.

The creditors of this session require that you check in regularly to make sure you are always paying attention. Please click the button below to indicate that this is you. Anthony J. Jannetti, Inc. is a supplier authorized by the California Board of Registered Nursing, Supplier Number, CEP 5387. *Some materials are adapted from Rockett, J. et al. (2009). Patient assessment, intervention and documentation for the veterinary technician. Clifton Park, NY: Delmar.

For patients discharged from acute care, the return road may be loaded with potholes and speed bumps. For many patients, fear of the unknown is after a new diagnosis with a wound or exacerbation. Prerequisites for success: Complete the learning activity completely and complete the MRC online assessment. You can print your CNE certificate at any time after completing the assessment. Reference 1. Ayello EA, Capitulo KL, Fife CE, et al. Legal issues in the care of pressure ulcer patients: Key concepts for healthcare providers. International Advisory Group on Wound Management. 2009. www.medline.com/media/assets/pdf/LegalImplicationsofPressureUlce. Retrieved 14 October 2018.

Commercial Support and Sponsorship: No commercial endorsements or sponsorships have been declared. The choice of a dressing requires a multidimensional approach. Currently, no dressing can meet all the needs of a wound (infection prevention, promotion of reepithelialization, water balance, etc.). 1 Clinicians should weigh the advantages and disadvantages of the chosen association(s). The purpose of this section is to provide veterinary technicians with guidelines for writing the patient`s care plan of the veterinary record. As there is no standardized format for creating a veterinary care plan, the following principles are just one example of how a care plan can be formulated. Don`t let this be part of a complaint against you: “Among the duties that the defendants and their associates owed John Doe but failed to fulfill was the duty to properly record his condition, assessment, care planning, history, and supervision in order to improve his progress and well-being.” The general answer is that when I look at records, I look for a general culture of patient care, including rotation and positioning.