Medical Record-Keeping: Dealing with Special Events
Jeannine LeCompte, Compliance Research Specialist
While most medical records will consist of routine, pre-planned treatments, there are always going to be exceptions or emergencies, and it is important to ensure that these events are properly recorded. Examples include unwitnessed injuries,falls, unexpected resident behavior, and “real life occurrences,” such as accidents immediately outside the facility.
Skilled nursing facilities should have policies in place to deal with issues such as who interviews staff in these events, and how long the permissible time gap is between the occurrence and documentation.
Records int he case of special events should include how the resident was transferred to bed or made comfortable; if there was any bleeding or injury, and if so, how it was treated; what transportation was used (if any); and what first aid or immobilization procedures were applied. In addition, any other procedure used an emergency must be recorded, e.g., when and where neurological checks were started, etc. Include anything that might be relevant at a later stage, such as whether or not a resident who fell was wearing care-planned footwear. Records such as these might be necessary to exclude any later charges of abuse or neglect, and can thus be as important as recording the incident.
In the case of unexpected resident behavior, all such events must be fully documented,even if they are initially regarded as eccentric. A tendency to get up and walk around at night might not be cause for alarm, but it could be used as a “cover”for inappropriate behavior. Wandering or elopement assessments should correlate to activity and therapy notes, and also social services notes regarding socialization/family participation.
With regard to night shifts, records should show the resident’s preference for waking and bedtime, and a toileting program or schedule should be determined as soon as possible after admission. There should also be a protocol for safety, such as lowbed/fall mats/frequent checks,at least until a resident’s routine is established.
Records should provide a complete picture of the resident, including nutritional requirements and exercise, as well as their emotional, social, and psychological well-being.
Finally, if staff members use a computer to capture medical records, they must always log out when finished, and should never share their user name or password with anyone.
