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 27 of 157

OSM560-April_DIGITAL_Layout 1 4/5/13 2:28 PM Page 28 MEDICAL MALPRACTICE Deficiencies in documentation There are 8 common charting errors that can compromise a liability defense: • failing to record pertinent health information; • failing to record nursing actions; • failing to correctly record medications; • recording on the wrong chart; • failing to document patient treatments; • failing to record changes in condition; • transcribing orders incorrectly; and • writing illegibly. POP QUIZ 3 Suit-Related True-or-False Scenarios The answers to these true-or-false questions might surprise you. • If it wasn't charted, it wasn't done. / False. In nursing school, we learned the age-old adage, "If it wasn't documented, it wasn't done." Although this is sound advice, and we healthcare providers should strive to document as much as possible, smart lawyers can successfully defend cases with less-than-perfect documentation by drawing inferences using other indicators. • Information shared in the post-op report is admissible as evidence in a case. / True. Communications among care providers during the post-op report, or even at change of shift, are admissible in a case. • Personal notes kept at a nurse's home are admissible as evidence in a case. / True. Facilities should educate staff on raising concerns with supervisors rather than keeping notes at home. — Jan Kleinhesselink, RN, BSHM, and Carmen Lester, RN, JD 2 8 | O U T PAT I E N T S U R G E R Y M A G A Z I N E | A P R I L 2 013

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