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For other articles and previous issues click here. September 13, 2004 Getting
It Right, Writing It Down Stick to the facts. Keep it clear, concise, legible … and do it now. In short, work as if you’ll be in court tomorrow. “Clear and precise documentation is essential for the continuity of care, accuracy of care, and quality assurance,” said Michael R. Bloyd, BSN, RN, RT(R). Bloyd presented the course titled “Medical Charting and Documentation” at the 76th Annual Conference of the American Society of Radiologic Technologists in Dallas in June. He emphasized the importance of technologists documenting their participation in patients’ care and the need to follow correct procedures in doing so to make sure charts include all necessary and accurate information. Many technologists, he said, either do not have adequate documentation tools available or work on separate information systems from other healthcare professionals in their facilities. Why It Matters Bloyd stressed that only information in patients’ medical records has significant holding in court, so any disparate systems used by technologists should be dissolved into the medical record, whether paper or electronic. “If it’s not documented, it didn’t happen,” he said throughout his presentation. When medical errors occur and patients take physicians, technologists, and/or facilities to court, the only solid defense for either side is efficient documentation and physical evidence. With no documentation to support guilt or innocence—let alone explain how or why the incident occurred—you and your facility face greater liability risks. For example, there may be no documentation of an IV being initiated or discontinued for a patient or medication or contrast being administered, but the patient could return to the emergency department following the procedure with an infiltration. With no documentation of the events, no one can know what did or did not occur or who may be accountable. The Ins and Outs of Charting To be accountable and responsible, Bloyd advised working “as if you’re going to be in court tomorrow.” He presented an “APPLE” standard for technologists to follow for all actions and documentation, making sure they are Administratively feasible, ensure Public protection, abide by Professional standards, and are Legally defensible and Ethically sound. To achieve that standard, Bloyd says data must be specific to each situation and detail every action taken, including questions asked about whether or not the patient is or could be pregnant and whether or not he or she is currently taking any medications. Bloyd also pointed out that technologists must learn
the approved abbreviations and terminology for their facilities
for two reasons: Just the Facts Both subjective information (ie, that which the patient provides about symptoms or experiences) and objective information (ie, that which the healthcare professional observed or obtained) should be included in charts. Bloyd said that technologists should state only factual observations and action they take, omitting any personal opinions or assumptions. When charting, Bloyd stressed the importance of using specific, measurable information (eg, numbers and measurements) rather than terms such as small, medium, and large because people can interpret those terms in various ways, affecting patients’ treatment and diagnoses. Legibility is important in deciphering charts, making easy-to-read writing imperative. Bloyd cited an example of numbers being misread, affecting the treatment of hypertension, where a blood pressure reading was confused between 164/80 and 104/80. The placement and inclusion of decimals are also crucial because, for example, there is a great difference between the administration of 0.1 unit vs. 1 unit of insulin. “Be brief, be bright, be gone,” Bloyd told attendees. “Say what you mean and mean what you say, 100%. Writing ‘patient confused’ can be an opinion, whereas ‘patient not able to identify self [reports an observation].’” Articles such as “a” and “the” are not necessary, and neither are “ands” and “buts,” he noted. Most importantly, document all the information necessary to explain events, he said. “Paint a clear picture. Charting is not a cliff-hanging mystery. Don’t leave them guessing. Again, if it’s not charted, it didn’t happen. Put everything in writing—even phone calls.” Do It Now He also advised that technologists use military time (if possible) for citing the time of entry and event occurrence to eliminate confusion between am and pm. He added that it is always important to note the time and date of entry to account for late entries (which should also note the time when the event occurred) and corrections. To validate entries, he said, signatures should include the technologist’s first initial, last name, and credentials. Bloyd added that no blank spaces should be left on the chart because that could “leave room for someone else to make an entry.” It is also important, said Bloyd, for the technologist to confirm that the referring physicians provide all the pertinent and accurate information needed to perform exams. “It’s the tech’s responsibility to gain the correct information for the correct exam and/or results,” Bloyd cautioned. For example, if a doctor orders a hand x-ray for a patient with symptoms including a history of back pain, the technologist should check and double-check the information so the exam they perform produces the desired results. Bloyd emphasized the difference between knowledge and comprehension, noting that comprehension is a level above knowledge. Knowledge, he said, is knowing what something is, and comprehension is knowing what to do with that information. In the case of technologists, they should apply the comprehension concept to all aspects necessary to do their job. IV Rules Finally, all the charting steps mentioned must be carried out with an eye on HIPAA privacy compliance. Technologists must take steps to protect and limit access to patient information once it is documented. Chart in a secure place and make sure it is safe when it is left. — Cristen Leaper is assistant editor of Radiology Today. |
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