The Medical Record: Your Best Defense – 2

Your entries in the medical record are recognized as the evidence of adherence to or deviation from a standard of care provided to a patient. The practice of nursing has become more complex, with the higher acuity, shorter length of stay, electronic medical records, and the increased regulatory compliance requirements including the meaningful use criteria introduced in 2010. Other factors impacting the provision and recording of patient care include health insurance payors, accreditation organizations, the public as consumers, and legal entities. You must be knowledgeable of the many factors impacting care first, and then, you must be able to satisfy these requirements and expectations, all at once, and with only a limited amount of time. Every entry in the medical record should be made with the regulatory agencies, insurers, state and federal laws, and other professional organizations in mind. It seems daunting, and probably at times, impossible.

So, you are probably asking, how close is close? Well, it depends on a couple of things. Let’s think of it is this way first. The higher the level of acuity, the more entries you would expect to be recorded in the record. Why? Because a higher level of acuity requires more frequent observations, more doctors’ orders, more interventions, more frequent follow-up etc. Hence, more frequent entries in the medical record. Now, the opposite would tend to be true as you move to a lower level of acuity. You would expect to have fewer entries in the medical record because of fewer doctors’ orders, fewer interventions, less frequent observations, less frequent follow-up etc.

Now, let’s consider when you have to make the entries so they are considered as “close” to the timing of the events as possible. This concept will vary, depending on the acuity of your specialty as previously discussed. I want you to think about when you prepare to make entries in the medical record, what do you do? Do you ever find yourself hesitating, reflecting back, and trying to remember which arm you put that IV in? Have you ever done that? Of course, you have. Then with your searching, you conclude that, ah yes, he was by the window. I had to move the over-the-bed table off to the side… yep, it was in his right arm. Now, what are you doing? You are talking to yourself! When you are talking to yourself, your facts are fuzzy. You are waiting too long to chart. When you find yourself talking to yourself the next time you go to work, I want you to stop, and evaluate your day at that point and make every effort to document sooner the next day.

Your goal should be “talk to yourself less and less every day”! If you begin to talk to yourself less and less every day, I guarantee your documentation will have improved, just by doing this one thing.

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