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.

Posted in Risk Management on Wednesday, August 1, 2018

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.