Judge each scenario below to determine if the documentation practice presented w
ID: 124982 • Letter: J
Question
Judge each scenario below to determine if the documentation practice presented would be legally defensible, meaning does it meet regulatory, accreditation, legal, and professional practice standards? Defend your answer.
1. Discharge summary dictated on 11/24/15 for a patient discharged on 9/30/15.
2. Process whereby emergency room transcribed reports are considered approved and signed if no corrections are made to the transcription within 48 hours of posting.
3. A faxed order and signature for a patient to receive physical therapy.
4. The following order handwritten in pencil:
Turn patient every 2 hours to prevent decubitus ulcers.
Dr. Timothy Reynolds 12/2/15 11:15 a.m.
5. The correction shown here:
Administer two units of fresh frozen plasma. ERROR –wrong blood product TR 12/18/15, 5:27 p.m.
Dr. Timothy Reynolds 12/18/15 5:25 p.m.
Administer two units of packed red cells.
Dr. Timothy Reynolds 12/18/15 5:30 p.m.
6. In a patient’s EHR for their last inpatient admission, a coder notices that the operative report is located under the discharge summary tab and brings it to your attention. You have it moved to the correct location within the account without annotation.
7. Nursing documentation for 10/31/15: 3:00 p.m.–11:00 p.m.
Administered dose of antibiotic. Walked patient in hallway. Sat patient up in chair. Performed vitals. Assisted patient back to bed. Checked on patient-resting comfortably, no pain. Walked patient in hallway and assisted to bathroom. Checked vitals. Administered antibiotic and pain medication.
8. Physician order: Give Lotensin 20mg. daily
Dr. Gregory Marshall 10/26/15 2:55p.m.
9. A physician copies and pastes his progress note from two days ago into his most current note, adding a brief comment that there is no change in the patient’s condition.
Progress note 11/4/15
Patient showing improvement in breathing. Responding well to antibiotic. Able to get out of bed and move around with assistance. Performed a bedside debridement of a lower leg ulcer, excisional, subcutaneous.
Progress note 11/6/15
Patient showing improvement in breathing. Responding well to antibiotic. Able to get out of bed and move around with assistance. Performed a bedside debridement of a lower leg ulcer, excisional, subcutaneous.
No change. Continued improvement.
10. An organization has a policy for record retention that states hard copies are kept for 7 years. In 2015, records purged for destruction included the following list:
MR #
YEAR
0015698
2006
0051482
2005
0742412
2007
0089364
2005
0009332
2006
0041127
2005
0065435
2008
0126525
2007
0039254
2006
0001153
2006
0248761
2007
0044879
2007
0964578
2006
0676766
2005
0037526
2004
MR #
YEAR
0015698
2006
0051482
2005
0742412
2007
0089364
2005
0009332
2006
0041127
2005
0065435
2008
0126525
2007
0039254
2006
0001153
2006
0248761
2007
0044879
2007
0964578
2006
0676766
2005
0037526
2004
Explanation / Answer
1. This is not legally or ethically acceptable. A discharge summary should be written just before the patient is discharged and copies should be handed over to patient and medical record section on same day. If discharge is written after 2 months, it is liable to be labelled wrong or incorrect with possible tampering or missing vital clinical information.
2. Not acceptable as all reports cannot be considered approved, if approving authority has not signed them out personally. If there is a delay in approval, (more than 48 hours) then this should be brought to the information of the approving authority who should approve them immediately before they are signed out. Proof of approval with documentation is must.
3. A faxed order is not acceptable. A clearly written or typed out order in the patients prescription or case file underlining the clinical course of patient with type of physiotherapy required with duration should be clearly mentioned. A sign of clinician with contact information should also be given in case of extra communication required for clinical queries.
4. Handwritten orders should be done in Block letters and should be legible and written in black pen. Pencil written orders are not acceptable and clarification should be sought before initiating treatment.
5. The order for wrong blood product is with error in bold letters is acceptable as the doctor has clearly stated ERROR and undersigned it. He has also issued a new order with fresh instructions with a sign. Also after making the error he has not scratched it out or overwritten, hence this is the way that wrong orders should be reversed.
6. Any change in position of reports shuld be annotated and this change informed to handing over authority so corrective action can be taken.
7. This is not an acceptable nursing note. Timings are not mentioned. Dose of administered drug not mentioned with type of administered route. Vitals not described. Not signed by nurse.
8. Not acceptable doctors order as their is no specification on how to administer the drug, whether oral or IV etc.
9. This is acceptable as long as the same has occured and there is no deviation from the that day to present day.
10.This list shows that many documents are kept for longer periods than what is mentioned in SOP. Hence one can assume that record maintaince and discard is not being monitored properly and this may have negative amplications in court of law and may not be accepted as lawful.
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