Documentation: A Crucial Aspect of Disclosure
Documentation is paramount in healthcare delivery because it memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of a legal action. Documentation also serves a crucial role in disclosing unanticipated outcomes, such as medical errors, medical mismanagement, system errors, or other unforeseen situations that lead to patient harm.
As part of the disclosure process, an appropriate member of the healthcare team should document the unanticipated outcome in the patient’s health record, including an objective summary of the pertinent clinical facts surrounding the event. These findings might include the patient’s condition immediately before and after the event, subsequent treatment, and the patient’s response to treatment.
The disclosure conversation also should be documented in the patient’s health record, including:
- Time, date, and place that the conversation occurs
- The information that is communicated to the patient/family
- The patient’s/family’s understanding, any questions they ask or information they want clarified, and any responses provided
- Names of those present for the disclosure conversation, and who will be responsible for follow-up communication with the patient/family
- Next steps for patient treatment, care, and communication
- A notation that disclosure was based on information available at the time of the conversation with the patient/family.
Documentation should be completed as soon as possible following the unanticipated outcome and updated accordingly as new information becomes available. To learn more about the disclosure process, see MedPro’s guideline and checklist about disclosure. For free continuing education, see MedPro’s programs Disclosing Unanticipated Outcomes: Creating a Patient-Centered Organizational Approach and Disclosure Case Review: A Workshop for Providers, Staff, and Leadership.
For more strategies related to documentation, take advantage of two free MedPro checklists: Documentation Essentials and Electronic Documentation.
