Homework Question on Healthcare and Law
Documentation and Regulatory Compliance:
- Analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit.
- Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence (APO).
- What APOs have to be reported in your state? ( florida)
- How would charting corrections be perceived in a court of law?
- What are the implications for handling of forensic issues?
Homework Answer on Healthcare and Law
Charting by exception involves omitting lengthy narrative entries to minimize repetition of data. This method is beneficial because it underlines abnormal data and points out patient trends. In addition, it eliminates duplication and minimizes narrative charting time. However, some of the disadvantages of charting by exception are that it omits specific data that could be essential in defending healthcare professionals or patients during court proceedings. Besides, it requires retraining of staff to get used to the unfamiliar ways of record keeping (DeWit & O’Neil, 2014).
When a nurse notices an adverse patient occurrence (APO) during medical charting, he/she should follow appropriate procedure to correct such errors. Nurses should determine exactly what should be corrected, as some errors may not necessarily require correction. Nurses should avoid wiping out or scribbling out errors. Instead, they should rewrite the report and incorporate omitted information.
Some of the APOs are quite sensitive to ignore and whenever they are discovered, they should be reported to the state. In Florida, adverse incidences such as death of patients, spinal damage, and surgical procedures carried out to wrong patients, must be reported to the Department of Health under Section 458.351 of Florida Statutes (“How do I Report an Adverse Incident?”, 2016).Medical records are vital legal documents, which can act as evidence in case of medical lawsuits.