Documentation
The main purposes of medical record documentation are to ensure optimal patient care and to communicate appropriate and important information about the patient with other care providers.
For transport services, continuity and communication are vital to the safety and well-being of patients as they transition from one system and/or group of providers to another. The documentation provides an ongoing history of the patient's course through the presentation, hospital treatment, and transfer to the next medical providers and location.Additional functions of documentation are to provide a long-term record of the care given and evidence of regulatory compliance. A well- charted, complete record provides factual information for quality review and can help refresh one's memory for future testimony. Lawsuits, external inquiries, and, ultimately, trials typically occur several years after the events that form the basis of a claim or review. The medical record is permanent and may be considered, fairly or unfairly, a marker of the quality of care provided at the time of the event. It generally proves to be a touchstone for the credibility of all aspects of the case or issue.
The number of people who will be looking at the record can be large and can include the following: subsequent treating physicians, nurses, coders, reviewers, compliance officers, risk managers, quality and other departmental committees, utilization review personnel, medical records personnel, peer review committees, third-party payers, professional boards, government reviewers, patients and their families, patients' lawyers, insurance company representatives, defense attorneys, outside experts, judges, and juries. Although not all records will receive this scope of exposure, each report must be written as if it will; often providers do not know in advance which records will receive intense review.
Documentation should be complete, legible, and signed. The use of care maps, template documentation styles, and documenting by exception is gaining popularity in the field and in billing enhancement circles, but the medical narrative report remains a solid and reliable method to document the facts, sequence, and details necessary to justify quality of care on review or defend a lawsuit. Documenting by exception and template-only documentation may lack sequence (time) entries, details, and observations that are the heart of the care provided. When subsequent treating physicians, reviewers and juries are unable to get a clear view of the patient and the care provided, then there is often a negative view of the care providers and potentially a negative verdict from the jury.
What Should Be in the Record?
It is perfectly acceptable to use checkboxes for routine administrative entries, such as verification of contacts, completion of chart segments, onetime entries such as gender and religion, and inclusion or completion of routine tasks. Beyond those types of entries, a clearly written and legible narrative entry should be made for all conversations, orders, observations, interventions, and rechecks. These entries should be timed, and each individual transport team member should sign the record. The documentation should also clearly indicate which team member performed which function.
The record should include a summary of the referral information and become more detailed from the point of initial contact with the receiving facility by radio or on arrival. Details should include patient evaluation, interventions and treatment before arrival, treatment at the referring facility by the transport team, preparation for transport, vital signs on an ongoing basis, care provided during transport, changes in patient condition during transport, and patient condition on arrival at the destination. Any issues encountered at any point should be detailed carefully and objectively.
A wrap-up narrative should include details of any changes in patient condition after arrival at the receiving facility, to whom the patient was delivered, to whom report was given, and any issues arising at the receiving facility. Information should be documented factually and objectively. All entries should be timed as closely as possible.Details and narrative imply that the record will contain specific vital signs, observations, and other specific items of information. Some generalization may be necessary, such as referring to a patient's general condition as “unchanged,” but specific measurable items such as vital signs should be reported each time with numeric value. Comments such as “normal” or “within normal limits” are not generally useful for documenting or recognizing changes in patient condition unless those terms are clearly defined in the transport-documentation standards.
How Long Should Records Be Retained?
Medical records constitute very important evidence in a malpractice lawsuit. When they are lost or destroyed, then a court will generally allow a presumption that the records contained information damaging to the party that lost them. For this reason, medical records should be kept for at least the amount of time equal to the statute of limitations, which is the amount of time after an occurrence that a plaintiff may file a lawsuit. The statute of limitations is generally varies by state, and it is generally longer for minors. In some states, such as Arizona, the statute of limitations for minors ends at age 18, and there is an additional 2 years to file the suit. Therefore, medical records for a neonatal patient would need to be kept 20 years.
Transport services not only keep medical records but a variety of other business documents. Everything from payroll records (Department of Labor) to schedules to Medicaid contract and reimbursement records (Department of Health and Human Services) must all be kept for varying lengths of time as regulated by a variety of state and federal laws. Collaboration with legal counsel is necessary to ensure appropriate compliance.