Bariatric Times July/August 2007

Legal Perspective prominently in the file. The use of standardized charting symbols by all personnel is highly recommended. Please don’t cause your lawyer or anyone else who will read that chart or records any extra work or ambiguity.4 DN u obr abbtn! What does this mean? It means: Do Not Use Obscure Abbreviations. Similar to Bariatric Times • July/August 2007 something underhanded or illegal. It’s hard to redeem the character of that person at a trial or hearing no matter how good his or her intentions may have been.3 Make sure signatures and initials are clear. Please make sure that whoever signs the records has been clearly identified. It is difficult to figure out who needs to be on the witness list when you can’t figure out who Changing a record without notation as had their hands on the records. In a day to who, what, when, why, where, and and age when malpractice suits can how CAN BE THE KISS OF DEATH come up years after charts and records IN A MALPRACTICE OR are made, it is very important that we be LICENSING DEFENSE CASE. able to identify who signed particular entries. It’s hard not making up your own charting enough finding people we can identify given the very transient nature of symbols, you should avoid making up medical personnel, let alone the ones ambiguous abbreviations for words we can’t identify at all. The one that might be particular to your person we can’t find or identify may practice or geographic area. If you the one person on whom the entire deal with unique words or identifiers defense case rests. If you notice a and you want to abbreviate them, signature or initials in a chart or please make clear in the front of the file what you’re referring to in the record that seems illegible, be sure to abbreviation. note somewhere the name of the Accuracy. Please be very individual and then sign your name accurate in what you write. This and date the entry. Someone down should go without saying, but the road may thank you profusely for unfortunately it can’t. Say what you saving his or her career or mean, and mean what you say. You reputation.3 may have to defend what you’ve Note consecutive pages to written, and depositions can go round eliminate presumption that pages and round for hours over the were reordered or altered. If a incorrect use of a word, or the report or series of entries, such as nursing notes or patient encounters, inaccurate use of a word or phrase. If goes longer than one page, simply you mean “a patient should be note that page number at the bottom monitored weekly for further or top. If a dictated report in its developments of this condition” but entirety is six pages, each page write “we’ll just wait and see,” a should say 1 of 6, 2 of 6, etc. It’s a plaintiff’s attorney would jump all simple thing to eliminate doubt about over that and so would a jury. Please additions, deletions, or alterations of take the extra seconds it requires to the record. write exactly what you mean in the Use or create a standard records. charting or reporting format for No late additions, deletions, your office or department. Many or amendments without detailed standard charting or reporting notation as to why. If you must add to a record, amend a record, or delete formats already exist, such as SOAP something from a record, you need to notes, HEENT formats, or H&P formats. Discharge instructions are leave a detailed explanation about usually formatted, as are surgical who, what, when, where, why, and how the change was made. Accurately reports. Office charting formats for particular specialties also exist, but if and legibly write, date, and sign the you aren’t using these existing notation. These are exactly the types of issues plaintiffs and lawyers salivate The use of standardized charting over. You should always note that the symbols by all personnel IS HIGHLY change was made to increase the accuracy RECOMMENDED. of the record. Changing a record without notation as formats, then simply create your own to who, what, when, why, where, and and make sure everyone in the office how can be the kiss of death in a uses the same format and uses it malpractice or licensing defense case consistently. Everyone charting because it creates a virtually differently creates a presumption of unrebuttable presumption that the chaos and miscommunication. That’s person making the change was doing http://www.newdirectionsystem.com http://www.newdirectionsystem.com

Table of Contents Feed for the Digital Edition of Bariatric Times July/August 2007

Cover Editorial Message Table of Contents Editorial Board Letter to the Editor Malpractice Preventative Maintenance: Record Protocols and Happy Lawyers Resolution of Fibromyalgia Following Laparoscopic Roux-en-Y Gastric Bypass University General Hospital Bariatric Program at University General Hospital Journal Watch Category List Trade Name Index Company Index Products and Services

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