Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc. He wrote the below article for McKnight’s.
You’ve heard the adage: “If it wasn’t documented it wasn’t done”, but does anyone actually think that’s realistic or meaningful? Yet sadly, millions of dollars have been paid by nursing homes who unsuccessfully defended themselves against incomplete or absent documentation. There are not as many legal guidelines regarding medical records maintenance as you might think; however, there are essential legal aspects of charting to keep in mind. Poor legibility, lack of dating, timing, and signing entries, improper labeling, spelling/grammar errors, inconsistent data entries, use of unauthorized abbreviations, mistaken/erroneous entries, and delays and gaps in charting, are the most common findings under scrutiny during a records review process.
During the initial phases of discovery, the medical record is regarded as a repository of information. The contents and quality of the record speak volumes about the standard of care and any potential deviation. Therefore maintaining, organizing and storing medical records should be regarded with a high level of importance.
Most nursing homes have policies and procedures for responding to requests for medical records by an outside party such as a plaintiff attorney or family member. If your facility does not, immediately consult with counsel and establish one. This is not a corner to cut.
Does your policy instruct that MDS assessments should be included? Typically these assessments are not included as part of record requests. However, the MDS could provide details of a resident’s care over time; changes in medical condition, physical and cognitive functioning, medications, diagnoses and treatments. The MDS describes what the resident is at risk for and what you’re doing to prevent a negative outcome or worsening of a condition. The MDS can significantly influence the interpretation of care.
Set yourself up for success! These five tips will improve any record you produce.
•Instill within your organization awareness of the importance of handling, organizing, maintaining, and storing the medical records.
•Systematically and consistently conduct chart audits to determine potential problems and erratic trends in charting.
•Invest in an MDS data accuracy program to ensure that incongruent MDS data entries are identified early on before final submissions to CMS or third party providers.
•Incorporate analysis of the MDS assessment forms during the initial phases of the records review process; use the MDS assessment to guide the review focus.
Know that the medical record is always pulled for review, regardless of the type of claim or allegation. By establishing good policies, providers can save themselves many headaches.