Comments in chart lead to a lawsuit - Clinical Advisor Consider a policy that for visits documented and closed after a certain time period (7 days? There are shortcuts in all systems, and some clinicians havent found them and havent been trained. "If you are unable to reach the patient, it's also helpful to document that you tried to contact them in various ways," says Umbach. The information provided is for educational purposes only. Documentation pitfalls related to EMRs and how to avoid them. Incorporate whether or not you chose to consider a common alternative (e.g., an implant in a restorative case), summarizing your reasons for that decision and whether all or any part of the planned treatment requires referral to one or more specialists, along with the names and specialties of those involved. This can include patients who decline medication, routinely miss office visits, defer diagnostic testing, or refuse hospitalization. Co-signing or charting for others makes the nurse potentially liable for the care as charted. Such documentation, says Sprader, "helps us defend cases when the patient does not get the recommended testing and then either 'forgets' that it was recommended or is no longer living and her family claims that she would never, ever decline a recommended test.". Note in the chart any information that will affect either your business or therapeutic relationship. It can also involve the patient who refuses life-saving surgery. When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment. Refusal of care: patients well-being and physicians ethical obligations. Medical records must clearly reflect the decision-making process between doctor and patientand any third parties. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. The right to refuse psychiatric treatment. For information on new subscriptions, product
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