Page 13 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

discharge summaries improved the average quality of the

summaries by 21 percent while reducing the average dictation
time by 67 percent. This study also emphasizes that the quality

of documentation—as measured by the usefulness of the
information provided—is more important than the quantity.
2

What Should Not be Documented or Maintained

in the Medical Record

Incident reports or other non-patient care information should
not be included in the medical record. Only clinically pertinent

incident-related information should be entered in the patient
record. Billing records and peer review documents should also

be kept out of the medical record. Most communications with
your attorney are legally privileged and, as such, are not subject

to discovery. These communications should be kept separate
from the patient’s chart, thereby eliminating the possibility of

their being photocopied or provided to the opposing party
without a court order specifically compelling their production.

Documentation: Pitfalls in Electronic

Health Records

An analysis of medical malpractice cases found that incorrect

information (e.g., faulty data entry) was the top EHR-related

contributing factor, contributing to 20 percent of reviewed
cases. Which EHR vulnerabilities are most troubling? CRICO
3
(the patient safety and medical malpractice insurer for the

2 Rao P, Andrei A, Fried A, Gonzalez, D, et al. Assessing quality and efficiency of discharge
summaries. Am J Medical Qual 2005;20:337-43
3 Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk
Manag. 2015;34(3):18-25.

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