In the Medical Records world, I have come across a variety of documentation species. Some are more dangerous than others. A number of them can sink their teeth into you with a lawsuit. Others can lead you to survey citations, medication errors, delay or denial of reimbursement, and poor care. Let us venture into this frightening documentation jungle and see some of these strange creatures at work.
The Exterminator.This breed uses white-out to eliminate all traces of documentation and is probably one of the more dangerous species. Their actions can have serious consequences in the form of a lawsuit by raising the questions: What are you trying to hide? Why are you trying to hide it? Are there other omissions in the record? Reimbursement may also be denied. Altering records is considered falsification, also known as fraud. When a record is subpoenaed, it usually needs to be certified that it was generated in the normal course of business. How can this be done if an entry has been obliterated or tampered with?
I like to ask The Exterminators I find if they would buy a house or a car if there was white-out on the deed or title. This usually gets a surprised reaction. I then explain that the record is considered a legal document just as a deed or title would be. Many staff don't realize this; to them, the record is just something they write in.
No white-out should even be permitted within reach of the nursing units. When an error occurs, it should have a line drawn though it, the word “error” written next to it, and the correction made, initialed, and dated.1
The Abbreviator.This species speaks an alien language, to wit:
Translation: 72-year-old white widowed woman, brought in by ambulance, admitted to skilled nursing facility for short-term rehabilitation. Status post-percutaneous transluminal coronary angioplasty, right total hip replacement non–weight bearing. Alert and oriented to person, place, and time. This is a fairly simple example of their language, showing that this species habitually uses unapproved abbreviations.
The facility should have an approved abbreviations list,2 and the list should be reviewed regularly. Any abbreviation that could have two or more meanings should specify in which meaning and in what context it should be understood. Several reference books of abbreviations are available that can assist in compiling this list.3,4 There also should be a listing of dangerous abbreviations that must not be used.5
The Cryptographer.Handwriting, handwriting, handwriting—that's the obstacle when dealing with this creature. This species believes that if they write illegibly, their note can say what they want it to say if questioned at a later date. This species is closely related to The Exterminator. Residents are at great risk for medication and treatment errors if orders are illegible, and there are legal and reimbursement implications, as well.
As the old saying goes, “If it isn't documented, it isn't done.” But I advocate a new saying special to this species: “If it isn't legible, it isn't done.” If the note/order is illegible, it should be rewritten in the next available space and noted as such. And there can be no changes once the note/order is clarified.2
The Better-Late-Than-Never.This beast prefers to write its notes weeks after the event:
When this note was written, the resident had a brain tumor and was being evaluated for treatment. Better that documentation is missing altogether than embellishing on scantily remembered facts. The more time that passes, the less reliable the entry becomes. If this nurse was put on the witness stand, she would have a tricky time defending her ability to recall the resident's status six weeks after the fact, especially since there was a progressive decline.
The Replicater (aka The Copycat, The Parrot).This species usually inhabits care plan review sessions:
They just copy the previous note. Review after review (year after year), the evaluation is the same. What progress have residents made toward goals? It is difficult to say. Certainly, if no progress toward goals was made, maybe the goals and interventions need to be reevaluated.
It is more appropriate to indicate:
This is a more informative note. It shows that you are aware of the goals, evaluated the resident's progress toward those goals, and adjusted them accordingly.
The Phantom.This creature asks others to leave blanks so that she can document later. Usually, though, The Phantom never returns to document. My personal favorite: The Phantom attaches a bright pink sticky note saying “Leave space for XYZ.” There is nothing like giving the surveyor a signpost: “Hey you, look! This note is missing!”
Sometimes The Phantom does return to document, and then one of two things happens: (1) There is not enough space and she tries to squeeze the note in by writing really small, especially toward the end of the note, or (2) she leaves too much space and there is a huge gap between her note and the next note.
This beast is fooling no one. Like The Exterminator, The Phantom puts all documentation into question. When was it actually written? Was the writer able to recall the information accurately?
A late entry is a much better alternative—provided that The Phantom does not metamorphose into The Better-Late-Than-Never species.
The Exposer.This species provides too much information: