Risk management expert Kevin Klauer joins us today with some rapid fire documentation pearls. We had a similar discussion focused on the MDM when we had Mike Weinstock on back in September. Hopefully, we will have both experts (and others) back again in the future but this was a great talk focusing on some key pearls that we can all bring on the next shift.
You will have to listen to the podcast for all of the pearls, but here are some of the key points.
There are three reasons for documentation: The three key points of the chart are for continuity of care, billing, and for risk management.
Document for the miss: Although you are not aiming to miss a diagnosis, think about the high risk things you could miss for that particular complaint.
The exam may be obvious to you: Unless you put it in the record, the lack of a detailed exam may come back to harm you.
Explain why you did not get detailed: If for some reason the patient's condition does not allow for what you would normally do such as the acuity document this clearly.
Leave breadcrumbs: You do not have to detail out every little thought but you need to leave key words and phrases that will allow you to come back to those topics in more detail later.
Use quotations when beneficial: Quotes are beneficial when information is distinctly different than you were expecting (especially in mental health issues) or when patients use particular speech or phrases such as declining certain services.
Avoid curse words: Try to paraphrase when possible to give the point across without using the actual curse words as this does not always come out favorably for you.
Discharge instructions need to be reasonable: Discharge instructions need to have specificity to them in a manner that is appropriate especially with a time specific follow-up when listed. Make it clear that patients can return to the emergency department. Remember, these are your discharge instructions.
Do you like what you heard? Do you have other pearls? What future topics would you like us to discuss in future posts? Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at firstname.lastname@example.org, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere.
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