Professional Legal Nurse Consultants share five documentation problems that often appear in almost every medical record. As a certified Professional Legal Nurse Consultant (PLNC), it’s essential to comb through the medical record for problems and identify them. After reviewing tons of charts, PLNCs have found common threads you should know when you’re reviewing medical records.
Instead of sifting through the electronic health records (EHR) by starting from scratch each time, why not simply have a checklist you can use to make your merit review easy? Look no further.
We interviewed Professional Legal Nurse Consultants and below they reveal five documentation problems you should look for in your medical record reviews. They each said there are common themes that you can spot throughout. And, the more EHR’s you look at, the easier it comes.
- Expect the medical record to be disorganized. The first thing you should do as a PLNC, is to organize the medical record into sections. You can’t help but look at the charting as you’re doing this, so consider this a “once through”. When you go to really read the chart, you’ll already have an idea of what’s going on.
- Almost all charts have missing documents. Don’t panic. Make a list of “Missing Documents” including those you’d expect should be in the chart. Even if the facility does not have such a document, at least you’ve identified it.
- Check the timing of the entries. Don’t be surprised to find that the health care provider documented “ahead of time”, meaning the task was performed in advance of doing it.
- Look for abnormal findings. You need to know what’s “within normal limits” to know if this patient’s findings actually fall within those. A blanket statement that the patient is within defined limits does not necessarily mean that is so. For example, keep a list of the ranges of lab values you’ll commonly encounter.
- Find where patient complaints have been communicated to the health care providers. Often, patient’s complaints are in the medical record but there’s indication whether or not those complaints have actually been communicated to the patient’s nurse practitioner, physician, or other health care provider. Merely documenting them may not be enough to absolve the individual who documented it of liability.
While there are different kinds of charting software out there, PLNCs found that there are common threads among all documentation software programs. They’ve said repeatedly, when you encounter a new chart, expect your nursing knowledge of charting to come in handy.
You’ve seen all kinds of charting in your nursing career. Know that your experience can be a confidence booster!
Whether you’re reviewing medical records in case about a fall, malnutrition, medication adverse reaction, or practically anything else, know that these five problems rear their heads repeatedly. No sense “reinventing the wheel” when others in the same field will tell you what you’ll likely encounter.
As a Professional Legal Nurse Consultant, you can tackle any medical record you undertake to review. Other PLNCs who have come before you have seen it, have done it, and they’re doing it. Take comfort in the fact that as a PLNC, you’re competent to handle it.
P.S. Tell us what common documentation problems you find.
