Page 41 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

This case highlights the need for contemporaneous

documentation, ensuring anyone authorized to make entries
into the EHR have his or her own individual access and serves

as a caution against making entries following notification of an
adverse outcome.

Avoid Jousting or Finger-Pointing

Jousting or finger-pointing usually occurs when another

healthcare professional intentionally or unintentionally makes
sarcastic, disparaging or self-serving comments about prior

care. Jousting can also occur when potentially damaging
remarks are made outside of patient care about a particular

physician, a hospital department (emergency department,
radiology, lab, etc.), the nursing staff, equipment, EHR, or

administration. Criticizing other healthcare professionals in
the medical record is likely to result in your unintentional

involvement if the care is challenged. You could even end up
becoming an “expert witness” against a colleague in a medical

malpractice lawsuit.

Criticisms or other derogatory remarks are often a result of

frustration with other staff or ineffective systems. Rather than
venting about the outdated equipment that “caused the medical

error”, address these issues through the appropriate chain
of command and not through the patient’s medical record.

Additionally, be careful not to make comments that can be
perceived as critical; for example, a note that “Patient admitted

after being told by PCP that his urine showed ‘lots of sugar and

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