Three Traps In Medical Record Documentation
By: Richard Curtis
We all know that clear, accurate, and timely documentation into a patient's medical record is critical for demonstrating compliance to CMS regulations and standards by accrediting organizations. Here are three traps to watch for:
Charting by Exception
Charting by exception usually involves documenting only what is different or abnormal. Otherwise, the lack of documentation is taken to mean that no issues or problems were identified. While charting by exception is technically permitted, it's use leaves your hospital highly vulnerable to citations during a survey. This is especially true when a regulation or standard clearly requires that documentation is contained in the medical record.
The simple problem with charting by exception is that neither the hospital nor the surveyor can determine if the lack of documentation is due to the fact that no issues or problems were identified, or the fact that the care, treatment, or service was never rendered.
The only thing known for certain, is that the standard or regulation required that the patient's medical record contain documentation – and it's not there. It gets back to what we were all taught in school, "If it isn't documented, it isn't done".
Within Normal Limits
Most medical records have a mechanism to "check a box" that indicates certain assessments were within normal or expected limits (WNL), rather than making the clinician document all that data. It's a great time saver and is certainly acceptable to both CMS and accrediting organizations. You'd be surprised though how often hospitals forget to do one simple thing; define exactly what is considered WNL.
A definition or description of what constitutes WNL is necessary to assure a common understanding. Otherwise, what is considered normal and expected may vary among different practitioners. It's exactly that type of variation that is fertile ground for citations during a survey.
Ideally, the description of WNL should be contained within the medical record itself. That way, it archives automatically when the record does. If the description is in the policy, than the iteration of the policy that was in place at the time the patient received care would need to be archived and made available at the time the record is reviewed or examined.
Summary charting usually involves a single entry into the medical record that captures multiple individual instances of care, treatment, or service. It's another great time saver, and both CMS and accrediting organizations allow for it. If a clinician is going to summarily chart, he or she needs to be cognizant of the following:
- The content of the entry must have sufficient detail to demonstrate that care, treatment, and service was actually rendered. For example, it is not acceptable to simply state that a patient in restraint was "monitored and cared for during the shift". The entry needs to describe specifically what monitoring consisted of and the specific care provided.
- Time sensitive information must be clearly identified. For example, if your hospital policy requires that neuro patients are assessed every four hours using a coma scale, then summary charting must clearly state when the patient was assessed to show that assessments occurred in a timely manner.
Avoiding these traps will go a long way in assuring that medical record documentation is not only "survey ready" but accurately reflects the care provided to your patients.
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