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Four tips for clear documentation

Ambulatory Safety Monitor, March 17, 2004

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Clear documentation about patient education, patient privacy, and patient assessments are necessary for a successful JCAHO survey. Check out these four tips from McLaren Medical Management Inc. of Flint, MI, about how to make sure your documentation will be up to par.

1. Document patient education
McLaren staff write down the instructions they provide to patients about the adverse effects of medication. But they don't consistently record this information on a specific place in the chart. Some caregivers jot notes on the bottom of the record while others make notations in the history and physical portion of the record.

Thus, surveyors had to hunt for evidence that staff spoke to patients about medications, "although they gave us credit for what was there," says Bernadine Baumann, RHIA, McLaren's manager of ambulatory patient information services. "However, in the future surveyors may not take the time to look for this information."

2. Be specific
Writing, "gave out materials" was not specific enough for the JCAHO. Instead, staff learned to write down, ". . . gave materials to patient John Doe about the side effects of Demerol."

Remember that using a stamp to signify that staff delivered patient education is also insufficient in the eyes of the JCAHO. Surveyors wanted to see comments about the patient's level of understanding, Baumann says.

"They said that education is critical for well-baby checks," she says. "They want to see in the record what kind of information staff give parents at each interval of the child's development."

Ensure that the age-specific educational packets you give to parents about child care cover immunizations, prenatal care, nutrition, diseases, preventive care, and medication, among others.

3. Note pain management
McLaren staff struggled with its pain management plan-especially regarding which patients needed an assessment. Staff eventually agreed that if patients present a chief complaint of pain, then staff should assess them. Likewise, staff must assess patients with a specific diagnosis where pain is a significant component.

Staff use pain scales, such as the 1-10, and make sure to consistently note pain questions in a specific part of a patient's chart that asks about pain. The center held inservices that explained the importance of consistently documenting with a "yes" or "no," and writing down additional comments. In addition, the center offers pain scales in Spanish and Vietnamese because one of its sites is heavily populated by those nationalities.

4. Ensure patient privacy
Patient privacy extends beyond what happens in the exam room to the common areas. Surveyors kept a sharp eye on staff members in the reception and discharge areas to ensure that no one, aside from the patient in question, heard about a bill or account.

The JCAHO did suggest that the center look into placing signs at the reception and discharge counters stating that if patients are concerned about confidentiality when discussing issues with staff, they should inform staff to provide other means for this conversation.

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