Articles Tagged With: charting
-
Should Ethicists Hide Consult Notes from Patients?
Ethics consults often are accompanied by conflict, intense emotions, sensitive or controversial topics, and disagreements about values. Ethics notes tend to incorporate more narrative and explicit analysis than other clinical notes. For the sake of transparency, instead of shielding notes, consider excluding details that are likely to cause harm.
-
Documentation Mistakes Lead to Significant Malpractice Awards
Ensure charts are generated honestly, and check to make sure key care decisions are carefully documented regarding consent.
-
Legally Protective Charting Sticks to the Facts
Charts containing emotional statements, accusations, and speculations might be compelling reading, but they are legally problematic.
-
Legally Protective Charting Sticks to the Facts
Charts containing emotional statements, accusations, and speculations might be compelling reading, but they are legally problematic.
-
Documentation Mistakes Lead to Significant Malpractice Awards
Ensure charts are generated honestly, and check to make sure key care decisions are carefully documented regarding consent.
-
EP Could Be Deposed if Patient Was Misdiagnosed at Another ED
Beware making well-meaning statements or criticizing other clinicians in front of patients.
-
Detailed Charting on Handoffs Stops Legal Finger-Pointing
The ED chart should include a concise summary of the clinical information that was conveyed, a plan for disposition and next steps in care, and a clear transition of care.
-
Artificial Intelligence Documentation Assistant Shows Promise for Healthcare Charting
Advocates are seeking relief for physicians overburdened with too many administrative tasks.
-
Problems When Calling Patient a ‘Drug Seeker’
Is this drug-seeking label truly needed to complete the chart? What message are you trying to convey, and to whom? Who is going to read that chart once you close it, and why?
-
Checkbox Charting Is Problem for ED Malpractice Defense
Make sure the ED uses modified templates to allow clinicians to add free-form text. Carefully review the record for accuracy before signing the note (including automatically populated checkboxes), either contemporaneously or close in time to the encounter. Finally, maintain a strong compliance program with regular medical record audits, including a review of electronic health record systems.