The Unexpected Outcome - What to Document

Words are interpreted in so many different ways and context is important. It is essential to be careful of the words you choose to use – especially when documenting events in your records. As a general rule, your records should not contain words such as "mistake," "error" or "inadvertent," which might lead the reader to a negative conclusion about the care and treatment you rendered.

So, when the "unexpected" outcome occurs, immediately – or as soon after the event as possible – document: 

  • The date, time and place of the event
  • The complication or situation
  • A factual account of what happened
  • The people present when the event occurred, including their names and titles 
  • If the primary provider was not present, note his or her name and time notified
  • The patient’s condition immediately before the event
  • The patient’s condition immediately after the event
  • Your appropriate and aggressive response to treat any complications
    • Any action taken
    • Treatment provided
    • Diagnostic tests ordered/done
    • Consults ordered and referrals made
    • The patient’s responses to the medical intervention
  • A follow-up plan until the condition is resolved:
    • If the patient is released to home, follow up with a phone call (document this action and the patient’s response)
    • Document both positive and negative findings
    • Document conversations with family members/caregivers, including their names and relationship to patient

For assistance from our claims professionals on this topic, please contact us.