Documenting the Unexpected Outcome
by Kathy Everitt
Friday, July 20, 2018
One of the first lessons I learned as a risk manager was that there are no “bad” outcomes. There are, however, “unexpected” outcomes.
Words are interpreted in so many different ways and context is important. It is essential to be careful of the words you choose to use—especially when documenting events in your records. As a general rule, your records should not contain words such as “mistake,” “error” or “inadvertent,” which might lead the reader to a negative conclusion about the care and treatment you rendered.
So, when the “unexpected” outcome occurs, immediately—or as soon after the event as possible—document:
- The date, time and place of the event
- The complication or situation
- A factual account of what happened
- The identity of people present when the event occurred, including their names and titles
- If the primary provider was not present, note the primary provider’s name and time notified
- The patient’s condition immediately before the event
- The patient’s condition immediately after the event
- Your appropriate and aggressive response to treat any complications
- Any action taken
- Treatment provided
- Diagnostic tests ordered/done
- Consults ordered and referrals made
- The patient’s responses to the medical intervention
- A follow-up plan until the condition is resolved:
- If the patient is released to home, follow up with a phone call (document this action and the patient’s response)
- Document both positive and negative findings
- Document conversations with family members/caregivers, including their names and relationship to patient
For assistance from our claims professionals on this topic, please contact us.