Posts Tagged ‘Documentation’

Nine Wound Care Documentation Pitfalls to Avoid

Friday, May 12th, 2017

Nancy Collins, PhD, RDN, LD, FAPWCA, FAND

Lawsuits often are settled out of court because the medical record documentation is not defensible. Incomplete, illogical, and inconsistent records are far too common, so it is important to avoid the common pitfalls.

9 Wound Care Documentation Pitfalls to Avoid

 

After reviewing hundreds of medical charts involved in litigation, I noticed many of the same problems occurring in the documentation over and over again. From New York to Florida to California, it is remarkable how the same inconsistencies, errors, and oversights tend to stymie the defense of a case. The goal of every healthcare practitioner is to have complete, accurate, and timely documentation of the medical care given to each and every patient. Here are nine wound care documentation pitfalls to avoid.

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The Great (Legal) Debate About Turn and Reposition Documentation

Friday, April 7th, 2017

Nancy Collins, PhD, RDN, LD, FAPWCA, FAND

Documentation of turning and repositioning often leads to legal problems as some healthcare providers chart by exception and others chart at the point of care.

The Great (Legal) Debate About Turn and Reposition Documentation

 

“The hospital never turned the patient, and therefore the patient suffered a serious pressure injury,” declared the plaintiff attorney. The defense team shot back, “Whoa. Slow down. Never is long time, and of course we turned the patient.” How can a basic care intervention such as turning and repositioning have two totally opposing views?

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Intake + Output = Big Documentation Problems

Friday, October 7th, 2016

Nancy Collins, PhD, RDN, LDN, FAPWCA, FAND

Inaccurate and incomplete intake and output (I&O) records pose a problem in litigation, as well as a risk to the patient who requires monitoring of fluid balance for medical reasons. 

Intake + Output = Big Documentation Problems

 

“Would you agree that the nurses did not know how to do basic arithmetic?”

Of course nurses know how to add and subtract, yet I was asked this question in a very challenging manner by a plaintiff attorney. He had just showed me 3 weeks of I&O tables excerpted from the medical chart of the deceased plaintiff, and almost every shift was incomplete. The plaintiff attorney was reducing the problem to poor math skills, implying that not a single day was complete because the nurses who cared for this patient lacked the skills to add a column of numbers. He knew I would disagree because I was not going to say these nurses lacked basic math skills. But he also knew his follow-up question was the real reason for this math ploy.

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How do we protect ourselves, legally?

Tuesday, May 19th, 2009

Cindy Broadus RN and Nancy Morgan RN briefly discuss how to protect yourself legally. As Wound Care Certified Nurses and Professionals , we want to practice with peace of mind. Knowing ahead of time how to protect ourselves is half the battle. Document, document document!