Posts Tagged ‘Medical Records’

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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If it wasn’t Documented, It wasn’t done!

Sunday, October 11th, 2009

How many times have we all heard, “If it wasn’t documented, it wasn’t done”? Far too often, we’re sure. Seriously, we as clinicians should take note of our documentation practices. Below is a short clip (Part 1 of 4) in which WCEI’s own Cindy Broadus RN, presented to the attendees at the Wild On Wounds Conference in Las Vegas NV in September. Her session was titled “If It Wasn’t Documented, It Wasn’t Done! Documentation Woes”.

Here was the description of the session: The medical record is considered to be the most reliable source for determining what happened. It is a legal document, yet not always treated as such. With litigation lurking around the corner for every health care professional, we, as Wound Care Certified professionals, need to make sure our documentation is complete, concise and correct. Come on it and let’s talk about correct terms, techniques, and steps it will take to keep you out of trouble.

Cindy always knocks it out of the park! Great job Cindy!