Page 38 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

she suffered an anoxic brain injury resulting in permanent

disability and neurologic impairment.

There was a factual dispute regarding the patient’s swallowing.
The patient’s mother testified that she began having difficulty

swallowing a couple of days prior to the visit but the NP did not

record it in the chart. After learning of the event, the NP amended

the chart two days later and added, “Swallowing was intact. No

difficulty with secretions.”, which was discovered before trial.

Remember the metadata audit provides a complete analysis of
every keystroke (including additions, deletions, and changes),

when the entries were made and by whom, and how long a

particular document was open for review and revision. Let’s review

another case with several documentation and process issues:

Page | 38