Advanced Practice Provider Academy

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1 (+)Jennifer L'Hommedieu Stankus, MD, JD Advanced Practice Provider Academy Attending Emergency Physician, Group Health Physicians; Medical Legal Consultant to the US Attorney's Office; Medical Legal Consultant/Attorney licensed in Washington DC, Colorado, and Washington State; Medical Protective (MedPro) Emergency Medicine Advisory Board Member; Chair, ACEP Medical Legal Committee; Former Medical Malpractice Defense Attorney, US Army JAG Corps April San Diego, CA Documentation: Focus on the Priorities Documentation serves many masters. Medical documentation is subject to review by peer reviewers, billers and coders, state medical review panels, federal regulatory bodies and medical malpractice juries. Although all will be addressed, the presenter s main focus is on key concepts in documentation related to communication, transitions in care, patient transfer and malpractice risk reduction. Objectives: Incorporate an understanding of the goals of medical documentation into clinical practice. Apply the concepts of medical documentation to reduce exposure to medical malpractice litigation. Develop a system solution of communication to subsequent care providers and receiving facilities in order to optimize medical care and minimize medical error. Date: 4/14/2014 Time: 8:30 AM 9:00 AM Course Number: MO 02 (+) No significant financial relationships to disclose

2 Documentation: Focus on the Priorities Jennifer L Hommedieu Stankus, MD, JD 1

3 Why do we have medical records? Communicate patient encounter Elements of coding so you can be paid A record of what happened Peer Review Malpractice Cases Medical Boards Patient Complaints Types of Medical Records EMR T Sheets/Hand written notes Dictation Dragon and other voice recognition systems 2

4 Advantages and Disadvantages Pros and Cons of each type of recording system Don t focus on what you don t like about one system or other make it work! Change, like death, is inevitable Be a problem solver and a positive force! A Note on Scribes Accuracy Variability They should be your shadow Can be a great help 3

5 Key Elements of your Notes CC HPI ROS PMH/PSH Meds/Allergies Exam Labs/Radiology Diagnosis/Disposition Vital Signs Always part of the Exam section This is the first thing you look at when you pick up a chart and the last thing on discharge 4

6 What s Missing from that list? Medical Decision Making This can save you! Consultants Time spoken with and gist of conversation Notes may be different Unofficial consults Left AMA If a patient leaves AMA, don t discharge them Document conversation Try to get written AMA form signed Leave your EGO at the door Incident Reports NOT part of the record Discoverability Always stick with the facts There is a separate process for this use it 5

7 Other important thoughts ALWAYS look at the nursing notes and document discrepancies! Notes on discharge Instructions Personal instructions to patients Make this a habit It is OK, indeed ENCOURAGED, to tell your patient you don t know what the diagnosis is. What should NEVER be in the record Personal judgments about the following: Patients Other providers/care given by other providers You need to state only the facts, never assumptions Example a fact witness versus an expert witness testimony 6

8 Alterations of the Record Discovering abnormal labs/radiology reports after the patient has left Discovering a bad outcome sometime after discharge Most records have time and date stamps Once saved, changes will be tracked and easily identified Appearance can be everything How to handle poor interactions Stay professional Pretend you will be on video and that that video will be played in front of colleagues and family in court or other public venue Get charge nurse involved They will also have documentation DOCUMENT the encounter Problem and solutions offered 7

9 Writing complete notes in a busy ED? Habits DOT phrases Acronyms Dictation/Dragon Not ALL charts require more than the basic elements 8

10 Medical Record as Evidence Think of this as a positive if you have a good system! Systematic approach Revisit the record prior to discharge Some EMRs have stops prior to discharge Elements of documentation for each problem type! If it s not in the record and not a documented habit, it didn t happen Trick of the Trade Missing things is easy Keep a quick list of what you ordered and what you need to do/review 9

11 High Risk Complaints in EM Chest Pain/ACS/PE/Thoracic Aortic Dissection Orthopedic injury/foreign body/wounds Headache/SAH/Stroke/spinal injury/menningitis Abdominal pain /AAA/Appendicitis Testicular or Ovarian Torsion/Ectopic Pregnancy Sepsis Homework at this Academy Think about WORST FIRST and what you have to document to rule that out in each lecture you have today. Make notes on what you should document for exam, and what labs and studies you should consider ordering for each major condition, and finally what must be in your medical decision making. 10

12 At Work Take two minutes before each patient discharge and think about the case Is your documentation complete? Will another provider be able to know what was done and what you were thinking? What is on the differential? Have you adequately addressed the biggies? Does the clinical picture, results, and exam make sense? Ask another provider, or go back and rethink if not Invite the patient back if not better or if something changes Documentation Conclusion Be Complete Make sure it makes sense and is easy to follow Clear clinical picture at presentation Care given/diagnosis Disposition/Plan Your medical reasoning This is for your protection AND for better patient care, so do it right! 11

13 Questions? 12

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