One Dozen Things
Document, Document, Document!
Scenario Analysis
In this scenario, an attending physician is reviewing the charting done by a resident. With her assistance, he locates a procedure note regarding a spinal tap that was done on the patient. The attending is concerned because the note does not indicate that the results of the patient’s CT had been reviewed before proceeding with the spinal tap. He points out that it is critical not only to have seen those results before proceeding but to document that they had been reviewed prior to the spinal tap. The resident is somewhat exasperated and doesn’t seem to understand why it is “such a big deal.”
It is “a big deal” because, unfortunately, if something is not properly documented in the medical records in a timely manner, legally it can be called into question whether it actually occurred. The documented event may be a procedure, a laboratory or x-ray result that might influence patient management decisions, a conversation with the patient or a consultant, or anything else that might allow a reconstruction of the course of a patient’s treatment. It may not be true, but for legal purposes the principle is, “if you didn’t document it, you didn’t do it!”
Beyond meeting the legal requirements for documentation, good medical record keeping serves several other purposes. Good notes allow colleagues and other members of the health care team to understand what is going on with the patient, what the plans are, and the rationale for the current treatment. This facilitates collaboration and improves patient care. It is important not only to enter accurate, clear, and timely information into the patient’s medical record, but also to carefully read all patient note entries made by others.
Finally, it is just as critical that you never enter false information into a patient record or to try to alter information previously entered. If an entry has been made in error, it should be deleted in such a way that the original note is not compromised, and the initials of the person making the new entry, as well as the date and time of the correction, should be noted.
