Policy on disclosure shows decisions on proper content

The following is a sample section of a policy and procedure for disclosure documentation offered by Fay Rozovsky, JD, MPH, president of the Rozovsky Group, a risk management firm in Bloomfield, CT. She cautions that the specifics of state law, health facility bylaws, and other requirements should be included in the policy and procedure to make it consistent with other administrative documents of your organization.

Procedures:

1. Core Content — Progress Notes. Following communication with the patient and/or family regarding unanticipated or adverse outcomes of care, the care provider who lead the discussion should write an entry in the progress notes that includes:

    A. Time, date and location of the discussion.
    B. The names of the parties in attendance and their relationships to the health care organization (physician practice) and patient.
    C. The name of any interpreters used in the communication.
    D. The language and dialect used by interpreters.
    E. The use of assistive devices in the communication.
    F. A summary of information communicated to the patient and/or family regarding the unanticipated or adverse outcome.
    G. A summary of questions posed by the patient and/or family, and the responses provided.
    H. Signature of care provider entering the notation in the progress notes.

2. Expressing Empathy or Regret. Any expression of empathy, regret, or being sorry for the unanticipated or adverse outcome made during the communication should be included in the entry in the progress notes.

3. Information from Patient or Family. Any information shared by the patient and/or family that may be relevant to the unanticipated or adverse outcome should be included in the entry in the progress notes.

4. Questions and Answers. In response to a question whether the patient and/or family had any specific needs or concerns and the response in return should be documented in the progress notes.

5. Follow-Up Information. If the care provider offered to provide follow-up on the results of an inquiry into the unanticipated or adverse outcome, or if the patient and/or family request it, this information should be included in the progress notes.

6. Factual Documentation. All entries in the progress notes regarding the discussion of unanticipated or adverse outcomes of care should be factual, nonaccusatory, and free of conjecture or speculation.

7. Subsequent Communication. Each time follow-up communication takes place between the care provider and the patient and/or family, the time, date, names, and relationships of the attendees, location, and means of communication (for example, telephone call), should be documented in the progress notes and signed by the care provider making the entry.

8. Content of Subsequent Communication Documentation. Each time follow-up communication takes place, the progress note entry should include a summary of:

    A. The information provided by the care provider.
    B. A summary of the exchange between care provider and patient and/or family.
    C. A summary of the questions posed by the patient and/or family and the responses from the care provider.

9. Documenting New Information. New, updated, or corrected information about the unanticipated or adverse outcome resulting from a review or investigation should be offered to the patient and/or family, and the progress notes should contain an entry that includes:

    A. The information provided by the care provider.
    B. A summary of the exchange between care provider and patient and/or family.
    C. A summary of the questions posed by the patient and/or family and the responses from the care provider.

10. Specific Circumstances. The following should be reported immediately to risk management:

    A. Requests by law enforcement or regulatory authorities to refrain from documenting the discussion of unanticipated or adverse outcomes.
    B. Requests by law enforcement or regulatory authorities to refrain from permitting the patient and/or family to see the progress notes regarding the discussion of unanticipated or adverse outcomes.
    C. Requests by law enforcement or regulatory authorities to access or copy the progress notes regarding the discussion of unanticipated or adverse outcomes.
    D. Requests from care providers not to document the discussion of unanticipated or adverse outcomes in the progress notes (or in the case of physician practices, the patient medical record).
    E. Request by union leadership not to document the discussion of unanticipated or adverse outcomes in the progress notes.
    F. Requests by the patient and/or family to modify, remove, or correct an entry in the progress notes regarding the discussion of unanticipated or adverse outcomes.

11. Chain of Command. Health care professionals who question the content of the progress note entry regarding the discussion of unanticipated or adverse outcomes should follow the health care organization Chain of Command Policy and Procedure.

12. Record Retention. Documentation of discussions of unanticipated and adverse outcome shall be retained as part of the progress notes in accordance with policy and procedure regarding retention of patient medical record information.

(Editor's note: This information is copyrighted by The American Society for Healthcare Risk Management in Chicago and used by permission.)