Documenting Adverse Events in the Medical Record Dos Don’ts
3. Establishing an Accurate Legal Record: In the event of legal or regulatory actions, accurate and unbiased documentation serves as an essential record of the event, including a clear description of what occurred, the clinical reasoning behind decisions made, the outcomes, and any follow-up required. It should also capture all interactions with the patient or their family members. By adhering to these principles, healthcare professionals can ensure that the medical record effectively fulfills its legal, informational, and educational purposes.
from the event, and to provide an accurate record in the event of legal or regulatory actions. The documentation should include a clear and unbiased description of the event, the clinical reasoning behind the actions taken, the outcomes, and any required follow-up. Remember to record all interactions with the patient or their family members. To ensure accuracy and quality in documentation, the primary team involved in the patient’s care should be responsible for correcting any errors and requesting necessary amendments from consultants. Institutional policies and regulatory mandates should guide any corrections or alterations to the medical record. The Anesthesia Patient Safety Foundation recommends designating an incident supervisor, an experienced clinician not directly involved in the patient’s care but knowledgeable about institutional policies and resources related to critical incidents. The incident supervisor should review the documentation before its finalization. A designated point person, such as the incident supervisor or a senior team member familiar with the situation, should coordinate all communication with the patient, their family, or legal representatives. They should document the details of these communications, including the time, date, method of contact, participants’ names and relationships, content of the discussion, reactions, and apparent understanding of the situation. Any offers of assistance, responses, questions asked, provided answers, necessary next steps, and plans to share new information should also be documented. Adhering to these guidelines ensures accurate and comprehensive documentation of AEs, promotes effective communication, transparency, and legal compliance when managing critical incidents. Conclusion Adverse events are unfortunately common in medical care. Regardless of the underlying cause, it is the clinician’s responsibility to accurately document these events and any interventions performed to assist the patient in a timely manner. It is equally important for the clinician to
Document as soon after the event as possible Date, time, and location of the event timeline
Delay documentation
Speculate about causes, use derogatory comments
Objective description of the event
Blame or finger-point
Clinical condition of the patient
Self-serving comments
Initial interventions to treat or mitigate the adverse outcome and patient response Consultation with specialists, timing, and their assessment and recommendations. Reports from consultants, including descriptions of procedures performed by them.
Refer to the event as a “medical error”
Apologize (be empathetic instead)
Mention or include an incident report
Laboratory, imaging, and other relevant results
Mention or include conversations with Risk Management
Code records if applicable
Mention or include conversations with legal counsel
Notifications to other health care providers
Neglect communicating with other providers
Notifications to patient or patient’s representatives, including a full disclosure note Expected outcome, follow-up plan, and management, if known
Forget to contact the patient or their representatives
Omit important details related to the treatment and prognosis
Incident supervisor review prior to finalizing notes
Disregard incident supervisor
As a general guideline, it is recommended to avoid writing emails impulsively, particularly when experiencing strong emotions. Emails can be subject to legal scrutiny. Documentation Guidelines The documentation of AEs is crucial as the medical record serves as a legal document and must accurately reflect the timeline of all events, decisions, and interventions involved in a patient’s care. It is also important to comply with federal mandates that grant patients access to their health information in electronic records. Therefore, clinicians and health systems have a responsibility to promote documentation that is accurate, factual, concise, easy to understand, and uses supportive language. When documenting an AE, there are three primary goals: to ensure all medically relevant information for continued patient treatment is available, to facilitate learning
document any discussions held with the patient, their family, or legal representatives. An exemplary medical record plays a crucial role in ensuring that future healthcare providers have comprehensive knowledge of the patient’s health history, including past AEs. It also fosters a culture of safety that values learning from mistakes while actively striving for improvement. Moreover, a thorough and well- prepared report is essential in the event of legal proceedings or regulatory investigations, and should provide a comprehensive account of the situation.
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ADVERSE EVENT DOCUMENTATION 107
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