Screening medical records is necessary to assess whether a case is meritorious or defensible. Some records illustrate a clear picture of events that occurred, but more often medical records create a mystery to uncover.
Some common challenges of screening medical records include identifying missing information, understanding the organization, or lack there of, as well as deciphering illegible handwriting.
As a nursing school instructor, I have taught hundreds of nursing students about documentation, specifically what to document and how to read a medical record. Unfortunately, the development of the EMR has provided a skewed understanding of documentation standards. Many staff believes that as long as they document in the required fields (i.e. check boxes) provided within the EMR system approved by the institution, that they are providing an appropriate level of documentation. However, no system can be fully equipped with every safe guard applicable to any situation that may occur in a healthcare facility. It is still the standard of practice to document when an adverse event occurs, regardless if there is a corresponding check box.
Some common challenges of screening medical records include identifying missing information, understanding the organization, or lack there of, as well as deciphering illegible handwriting.
As a nursing school instructor, I have taught hundreds of nursing students about documentation, specifically what to document and how to read a medical record. Unfortunately, the development of the EMR has provided a skewed understanding of documentation standards. Many staff believes that as long as they document in the required fields (i.e. check boxes) provided within the EMR system approved by the institution, that they are providing an appropriate level of documentation. However, no system can be fully equipped with every safe guard applicable to any situation that may occur in a healthcare facility. It is still the standard of practice to document when an adverse event occurs, regardless if there is a corresponding check box.
Most EMR systems include a “comment” section to allow healthcare providers to document a narrative note. Unfortunately, these entries are not always obvious when records are pulled because these notations may not correlate chronologically or by subject field. In some EMR systems, an asterisk, or other symbol, may indicate that an additional notation was made. However, depending on the font size, an asterisk may not be easily noticeable and if these additional notations are not in obvious order, it may be difficult to link their appropriate placement in a set of events.
This leads me to the issue of organization. Every EMR system is different and has its own pattern of organization. When an electronic chart is printed in it’s entirety, it may not appear to be in any obvious order. This can make it difficult to identify what events occurred or whether anything is missing. A legal nurse consultant can identify what is missing because we know the anatomy of the medical record and what should be present. Whether it’s a paper chart or EMR, one of the first things I do when I review a medical record is organize it and audit all necessary components to ensure the chart is complete.
This leads me to the issue of organization. Every EMR system is different and has its own pattern of organization. When an electronic chart is printed in it’s entirety, it may not appear to be in any obvious order. This can make it difficult to identify what events occurred or whether anything is missing. A legal nurse consultant can identify what is missing because we know the anatomy of the medical record and what should be present. Whether it’s a paper chart or EMR, one of the first things I do when I review a medical record is organize it and audit all necessary components to ensure the chart is complete.
When handwriting is illegible and an order, or notation, cannot be properly understood, patient safety is compromised. Sometimes, it may also be difficult to identify the responsible person for a particular entry due to an illegible signature or marking. It may help to enlarge the documentation to make it clearer. Or, a healthcare professional may be able to assist in deciphering the entry. Ultimately, depending on the degree of illegibility, it may be necessary to ask the individual who actually wrote the notation to translate. In regards to identifying a signature, hospital Quality Departments develop a “key” of physician signatures to correlate with all entries. They also obtain examples of legal signatures from their nurses and other healthcare workers.
Please share with me YOUR challenges of reviewing medical records.
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