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:

Occurrence Statements should never be entered in the chart. They are used for Quality Improvement (QI) purposes only. In some states this protects the Occurrence Statement from being discoverable in a lawsuit. Check with legal counsel to determine if this applies in your state. It bears repeating: the Accident Statement should never be filed in the chart. No QI documentation should ever be filed in the chart.

The Overlooker.This species never reads the previous note, or anyone else’s notes for that matter:

How can you write a note regarding the resident’s current status when he or she is hospitalized? Obviously, you are not assessing the resident. How can you write a note that the resident is on a medication that he or she is no longer receiving? Evidently The Overlooker is not reading the previous notes/orders and is lapsing into The Replicater’s habits.

The Palm-Off–er.This type tries to pass off the responsibility of documenting to another discipline:

If a resident is found smoking in his or her room, the staff member who observes this should counsel the resident about the hazards of unsupervised smoking in his or her room. If the staff member is nonclinical—for example, a housekeeper—that person should immediately notify the charge nurse, who should provide the counseling. This behavior puts all of the facility’s residents in jeopardy and should be addressed immediately. Smoking materials should be removed, and a policy and procedure regarding removal of smoking materials should be in place. A care plan should be developed (if not already in place.) As a follow-up, the social worker can also be involved and, if necessary, a team meeting should be held. If the social worker is actually referenced in the note, she should be told so that she, too, can document any interventions provided.

This practice of “palming off” documentation makes everyone look bad. It makes the person documenting look as though they have done nothing (and they have done nothing). Since the other discipline was never notified of the issue, they also appear neglectful. There should always be follow-through.

The Inventor.This is a unique species. They think they can create a form and, with sleight of hand, make it appear on the chart. All forms should go through an approval process (e.g., Policy & Procedure Committee, Forms Committee). This ensures that there is no duplication of information that is already being obtained in the chart elsewhere. Any time there is duplication, it introduces a potential for contradiction, which can have possible legal, survey, and reimbursement ramifications.

The form should also have a flow, be easy to complete, and be necessary. Each form should have an edition date. When a new version is adopted, the outdated versions should be discarded. The approval process should ensure that the new form captures the information the discipline is seeking and is a good use of staff time. It should also allow for version control.

The form should meet certain requirements, such as style and format particular to the facility (e.g., demographic information in upper right-hand corner, logo in the left-hand corner). The form should be appropriately designed so that no information is lost when holes are punched. This sounds obvious, but you would be surprised at how many times this inadvertent destruction occurs.

Finally, forms should be reproduced by a professional print company, or a master (clean) copy should be maintained for photocopying. A blurry, crooked copy illustrates that the facility is haphazard about its documentation. This also creates a problem for reproducing copies of the record for follow-up care. If the original is blurry, the copy will be even worse.

In sum, poor, ambiguous documentation can be suggestive of substandard resident care. The question in the surveyor’s, lawyer’s, or insurance company’s mind will be, “If this facility cannot clearly document, what kind of care are they providing?” This is the very last thing you want them to be thinking.

In addition to the other suggestions made to improve documentation, an innovative way to stay out of the quicksand in the documentation jungle is to in-service staff regarding documentation, both upon hire and annually. A great resource for this in-service is your Medical Records person. He or she probably has a set of pet peeves about documentation, and it would be useful to employ actual examples from his or her own charts.

Taken altogether, these steps will, hopefully, make all the Dreadful Documenter species extinct. And they will not be missed.

I Advance Senior Care

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