Accuracyfully documenting and completing health records is essential for a long-term care facility to minimize risk and liability. Written documentation supports and validates the actual events that took place during a resident's care or during an incident involving a resident. Should an incident occur-such as a fall-or or a resident becomes gravely ill, accurate documentation of events would be needed as evidence if the family or resident file a lawsuit.
For that reason, it is imperative to document the event on the resident's chart and follow the facility's incident reporting procedures. Completing both the medical record and incident report are important to support the defense of the facility if an incident is under investigation or goes into litigation.
Some examples include:
Recording resident fall history. The medical history of a resident who is at risk of falling should have every instance of falling recorded. This record should also include the resident's initial assessment of fall risk. If and when the at-risk resident falls, this documentation will help the care team continue to monitor, assess, and provide the proper interventions. Just as important is accurately reporting the fall incident, using the facility's reporting process. If any type of injury should occur as a result of a fall, the resident's accurate medical record, along with the reports of each incident can be used as evidence that staff acted appropriately on the resident's behalf and reported the incident accurately and in a timely manner .
Prescription drug use. Recording prescribed drugs on a resident's medical record is imperative to the proper care of the resident for the entire multidisciplinary team. This record must include the signed and dated physician's orders, when the drug was first administrated, any changes in dosage or changes in prescription, and any adverse effects that occurs as a result of the resident taking the drug. If an adverse event does occur, the incident must also be reported, following the facility's reporting process. Having these accurate records and reports is evidence and prevention against possible litigation, should anything happen to the resident as a result of drug interaction.
Keeping all medical records in secured areas. Because the confidentiality of a resident's medical history is legally and ethically required, it is extremely important to have all medical records stored in a secure and locked area. Only authorized staff should have access to these records. Records should never be left unattended, such as sitting on the counter of the nursing station or on the patient's bed, and when not being used, should always be kept in the secured area. Breaching the confidentiality of a resident's medical record could result in an invasion of privacy lawsuit. Staff need to be educated and clearly understand the importance of this policy and treatment resident's medical records using strict guidelines.