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Michael Carrese (Host): Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through Enterprise Risk Management. Visit ashram.org/membership to learn more and become an ASHRM member.

Grace Jones, MBA-HCM, CPHRM (Host): My name is Grace Jones and I'm the Director of Risk Management and Patient Safety for Baptist Health Medical Group. I'm here today with two guests, Melanie Collins and Tonya Rager. And together we are going to discuss documentation in the electronic medical record. So, I'll start out by saying that documentation is something that comes up on a fairly regular basis in my world.

Over the years, I've answered countless questions and provided guidance on several documentation issues. I'm asked routinely, what do I document? How do I document, can I remove something from the chart, you know, things of this nature? So, I'll tell you it's a challenge knowing what to include in the medical record.

And we work for a hospital system and we have policies and procedures in place that provide general guidelines, as well as what is required to be placed in the medical record. If you find that you have something that falls outside of those walls, if you have policies and procedures in place, always reach out to your risk manager or your legal counsel to ask for advice on how to document certain things.

I advise my providers that they should always document what treatment they provided to the patients, follow up advice, recommendations, discussions, non-compliance from the patient, any concerns that are presented by the patient or by their family members. I also ask them to document communication of test results. That's a really important one. Especially those that are of critical in nature because they usually contain follow-up actions. And I want to make sure that that's well-documented. So, I also advise them on what not to document and a few of those things, any information that will be privileged communication, as well as any indication that there's been a risk management investigation or an incident report has been completed. Things like that. So, now I'm going to introduce you to Melanie Collins, who is my first guest. She is the Patient Safety Officer for Baptist Health, and she's going to provide us with some examples of documentation errors, and omissions, things that she's seen and advised on in her many years in Risk Management. So, welcome Melanie.

Melanie Collins, SN, RN-BC (Guest): Thank you. Great.

Grace: So, just to get us started. Can you describe for us some documentation errors that you have encountered over your many years in risk?

Melanie: Well, over my years of service here in Risk Management and throughout my nursing career, I would probably say many documentation errors that I've seen include the use of the copy and paste function, charting by exception rule, lack of documentation of any significant event such as a fall, medication error, family issues, family dynamics going on, and many more other things that you could think of.

So, when I'm reviewing a medical record, and I go through the nursing flow sheets. It's very easy to determine if the copy and paste function has been utilized. And you can also tell if that has been used through multiple shifts or strictly just for that one shift. So, when I orient employees, I like to educate them and encourage them to document their own assessments at the beginning of their shifts. So when you come on at 7:00 AM or 7:00 PM, you need to do your own full assessment, clicking on all the boxes that are pertinent to your patient. And then throughout your shift, it is okay to copy and paste your own documentation. But not documentation of others. For example, IV sites seem to be a very popular one that they are normally in place for three to four days which is protocol. However, they forget to when they've changed them to discontinue that line and put the new line in and staff will just continue to document that throughout the chart.

And those are things we catch when we're reviewing charts, but it's not always easily detectable to the frontline staff members. Charting by exception is a way that most nursing facilities document, because it's easier that you chart the norm or the abnormal, I should say of things going on. And then the other things, we have a specific box where we can choose within defined limits. And those are criteria that's preset in our electronic medical record. But it's very easy for staff to forget to document some important assessment findings. So, I encourage them with their initial assessment, starting at their shift, to paint that picture, put even if it's a normal within defined limits. It's okay to put, say for example, the patient is tachycardic, but not much, has you know, pedal pulses are palpable. Go ahead and paint that full picture of how that patient is at that time. That way you can tell in future, well, on this day she documented this, but now it's not like that. So, there's a change in the patient condition. So, when we meet with staff members, during our investigations here in risk, they always look at it from a different viewpoint of what we see in the chart to how what they really meant to document in the chart. I think it's really eye opening for them that helps them in the future, like I need to make sure I paint that picture.

Other errors I've encountered including notes whether by nursing or physicians that have emotion or staff members' views about the event, whether an incident report has been filed, or my favorite one is that they have spoken to risk management. So, we teach the staff members that things such as incident reports and discussion with us or outside counsel, are considered privileged and protected from litigation. Therefore, we don't want them to be documented in the electronic medical record.

Grace: Well, thank you for that. So, I have, I have the same issues on the medical group side, where we have things that should not be in the chart. I had one time a provider wrote an order to contact the legal department. So, definitely things that we ask them to refrain from putting in there. So, thank you for that helpful information.

So, let's talk about audit logs. I know we work in the world of litigation and audit logs and audit trails, come up frequently. Tell me how, what did you talk to your staff about when it pertains to audit logs?

Melanie: So, when we start an investigation in risk management, one of the features that we can see on our end, that not necessarily the frontline staff can see is the actual true documentation time that it was actually placed in the medical record, not the time that they say that they did the actual documentation or performed that task with the patient. So, its always very eye opening for the staff of seeing that I can see you didn't chart that until three hours after you did it versus you charted it at 1220, but you really didn't document it until 1520. We explain to them that audit trails are discoverable in litigation. We try to protect them the best we can, but there are times that we do have to turn that over to the court system and it shows that you didn't document that until three hours later.

I also teach them that there are computers in every room, that is okay to go ahead and log into those computers, document what you need to document, whether you're doing a safety round or just going in to check on the patient, or you're taking them some medication, because we can prove what computer that was documented on that shows it was in that room on that particular date that yes, the patient was there with the nurse or the patient care tech, whichever it may be at the bedside, performing their rounding.

Grace: Okay, thank you. That's a lot of information. I know we, we have it come up time and time again in discovery responses they're asking to, to, for us to produce the audit trail for them. And not something that we're always willing to provide or can provide, but very important. So, thank you. So, Melanie, are there any other things that you would like to see included in the documentation that have not been mentioned?

Melanie: The only other recommendation I probably have that I've noticed and really have tried to educate the staff on is related to documenting those conversations you have with the patients, with the visitors, with physicians, other departments within our organization that may be involved in the care team. There's always more to the story than what's in the medical record, which is why we like to talk to staff members to get their perception of the event. We don't want you to go overboard, but stating the fact of those conversations with physicians, of I notified the physician due to such and such symptoms. No orders received. And if the physician becomes a little agitated or irritated, you know, it's okay to say physician not co-operative with recommendations for care or any guidance given, something along that nature. Because, seven years down the road, if this is when it's going to litigation, they may not know or recall that particular event. And if they truly document those true facts and statements, it might jog their memory a little bit during that time.

Grace: Absolutely. I agree. Very good advice. Okay. Well, thank you so much, Melanie. I appreciate it. I am going to introduce our next guest Tonya Rager, and she is an Attorney that Melanie and I both have the pleasure of working with. She's with Kincaid and Stills in Lexington, Kentucky. She has 25 years of litigation experience defending all types of healthcare providers. So, welcome, Tanya.

Tonya Rager, JD (Guest): Thank you, Grace. I'm happy to be here.

Grace: Wonderful. Glad to have you. So give us Tonya, we know documentation is of critical importance for a variety of reasons. Can you share with us some examples of the ways in which documentation can arise in a legal case?

Tonya: Sure. And I think I would echo many of the things both you and Melanie have mentioned on the podcast so far knowing what to include in a medical record can be really challenging. And that's why it's important to follow the policies on documentation, if you have one. If there is a policy that certain aspects of care be documented, within a certain interval of time, for instance, vital signs, every two hours, every four hours, whatever is called for that patient; it's really important to do that as close in time to those intervals as you can manage to do. Because later when you look back and you're in litigation you can't, you don't remember all those times that you went in and took the vital signs of the patient. And so the documents are very helpful.

And as I think Melanie called it, painting a picture. It can be really difficult to do sometimes when people get busy, things are happening quickly or when your priority really is the patient's care as it should be. But it is important to document for practical reasons, because for instance, many nurses and doctors and techs, they take care of you know hundreds of people within a couple of weeks, time span. And sometimes your interaction with those patients may be fairly short. For instance, if a patient comes in for a procedure where they just stay overnight and then they're discharged the next day.

In maybe even a month later, you may not remember that patient, or if you do, you may not remember all the details of the care that you delivered. So, it's really important to have that stuff in the record, if at all possible. Oftentimes in a lawsuit, which I defend lawsuits, medical malpractice, lawsuits, all the time on behalf of all kinds of healthcare providers, the issues that arise much later in time when I see the case is you know, this happened two years ago or three years ago, so you're not talking just even a month down the road. It's very difficult to recall what you specifically did with that patient two years ago.

I think Melanie mentioned earlier in the podcast that issues arise sometimes in the timing of the documentation. It is, from a legal standpoint, in defending a lawsuit, it really is important that whatever care is given to the patient, is documented as close in time as possible to when it was delivered or when an event occurred. Because if you wait, you know, two or three hours or the till the next morning or your next shift, it can later on appear that you're being self-serving because you may know further facts about what happened after that event or that care, when you don't really mean it that way. So, if you document it close in time to when the event or the care occurred, that question is not even created. So that's, that's an important thing.

I, I think again, as Melanie mentioned, the medical records that have the drop down boxes and self-populate, that is an issue in many of the cases that I've had. And I've had cases where the opposing side has argued that such information from a template was simply carried forward in a patient's medical record, even though the condition of the patient was different. And so, I always advise people, when I talked to them to be aware of what is being pulled forward, because some of those electronic medical records automatically populate those fields for you and you have to pay attention. Particularly for instance, on the review of systems, portion of the chart; a lot of times those will self-populate and you need to make sure you're reading each one of those things and that it is the current condition of the patient. A lot of other documentations issues can and do arise in litigation.

One of the most challenging ways that it does occur is when a provider documents judgments that are not essential or necessary to treatment of the patient. For instance, I've seen notes in medical records that say, things like this unfortunate young lady or this pleasant 65-year-old male. Now, most people think that those are innocuous, but if you get in litigation, it really implicates some sort of judgment that is being made toward the patient. And it may be relevant. It may not, but it, it creates an issue sometimes that wouldn't exist if that were not in the record. The most challenging times for in litigation where this arises is when someone puts in a note that at the time, they made the note, they didn't intend anything by it; but later on in the lawsuit, that becomes one of the central issues.

For instance, I've, I've had cases where it was noted, “it is unclear why this treatment was done for the patient", or "it's believed that the outside provider thought this is what was wrong with the patient, but we've ruled that out because of a test we did here at our facility" or "I've paged Dr. So-and-so five or six times and I've received no response." And I, while I know it's tempting to write those things down as they occur to you, just thinking about the way you phrase things like that can later on get rid of any potential issues in litigation that really shouldn't be issues in the first place.

So, for instance, instead of saying that you've paged them five times, you could just say paged them, this was the response, or there was no response, rather than commenting on the number of times and there's lots of other things that arise in litigation. It's very hard to predict. And so , in closing, I would say that what I advise people to do, because there's so many permutations in documentation and, and knowing whether that's going to be an issue in a lawsuit or not, is to really focus on the care that's being delivered to your patient, considering the input that you receive from family members, other care team members, and really focusing on what you're doing, because you keep, you really can't go wrong that way by noting what you've done and what the outcome is and the facts of taking care of that patient.

Grace: Absolutely. Great, great advice. Appreciate that so much. I think that's, that's just a lot of, a lot of really good information that will be helpful to our listeners. So I just want to say Melanie and Tonya, thank you very much, both of you for discussing this very important topic with us. I think that we hit on some really good points and I'm hopeful we provided the listeners with a lot of good and helpful information today. So, I appreciate you both participating. Thank you so much.

I am Grace Jones, the Regional Director for Risk Management and Patient Safety for Baptist Health Medical Group. Thank you for having us today.  

Michael Carrese (Host): This podcast is made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through Enterprise Risk Management. Visit ashram.org/membership to learn more and become an ASHRM member.