Documentation and Regulatory Compliance
Based on the information you have learned in the course so far and the readings, analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit. Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence (APO). What APOs have to be reported in your state? How would charting corrections be perceived in a court of law? What are the implications for handling of forensic issues?
Include at least 3 peer reviewed references
Expert Solution Preview
Introduction:
The field of medicine is highly regulated and requires careful documentation to ensure the safety of patients and healthcare providers. As a medical professor, I would like to provide an answer to the questions regarding documentation and regulatory compliance in medical practice.
Answer:
Charting by exception is a method of documentation used in medical fields where only significant findings or exceptions to the normal course of treatment are documented. This method can be advantageous in the case of a malpractice lawsuit as it limits the amount of information that can be used against the treating physician. However, the disadvantage of this method is that important information may be missed, leading to medical errors and poor patient outcomes.
When correcting mistakes in a medical chart, it is critical to use proper documentation procedures, such as drawing a single line through the error, initialing and dating the correction, and explaining the reason for the correction. The formatting of the documentation during an adverse patient occurrence should be objective and factual, avoiding any accusations or blame. In the state of California, APOs that must be reported include a patient death, serious injury, serious impairment, or unknown location. Charting corrections should be perceived as an effort to maintain accurate medical records, and the healthcare provider should be prepared to explain the reason for the correction in court.
In terms of forensic issues, it is important for healthcare providers to follow strict procedures for maintaining the chain of custody when handling evidence, such as blood samples and other physical evidence. Failure to follow proper procedures may lead to contamination of evidence and compromise the results of forensic analysis. Medical professionals should also be aware of their legal obligations to report certain medical conditions, such as child abuse and domestic violence.
References:
1. Welford C. Charting by exception and the electronic health record. J AHIMA. 2003;74(3):30-33.
2. Mehigan S, Nash DB. Medical documentation in an electronic age: charting a course for use of electronic records in litigation. Am J Med Qual. 2006;21(2):104-108.
3. California Department of Public Health. Reporting requirements for adverse events. Accessed July 18, 2021. https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AEOccurrence.aspx
