Outpatient Surgery Magazine

Marking Madness - April 2013 - Subscribe

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Page 26 of 157

OSM560-April_DIGITAL_Layout 1 4/5/13 2:28 PM Page 27 MEDICAL MALPRACTICE Jan Kleinhesselink, RN, BSHM, and Carmen Lester, RN, JD Suit-Proof Your Documentation Charting errors can come back to haunt you if you're sued. I n a malpractice case, the medical record can be either your best friend — or your worst enemy. Documen-tation is meant to provide the record of patient care, the patient's medical history, the basis for billing and reimbursement, quality-of-care indi- CHART THE COURSE The plaintiff's lawyer will dissect the medical record. cators, and possibly clinical data for research and education. Documentation is the story of the patient's experience across the continuum of care. But if your facility is sued for malpractice, the medical record will suddenly become most invaluable as a legal document. In court, the medical record is the care rendered. It will be introGET IT RIGHT duced as evidence at trial. Jurors view good The 5 Rights of Documentation record-keeping as an indicator of good care 1. having the right person 2. get the right information 3. about the right patient 4. on the right chart 5. at the right time — poor documentation can create an aura of poor care and damage your credibility. Here's how defensive documentation can protect you in the event of a suit. A P R I L 2 013 | O U T PAT I E N T S U R G E R Y M A G A Z I N E | 2 7

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