Is it accepted practice to include the name of a healthcare provider in the medical chart as long as the provider's role in a patient’s care also is documented?
Monday September 28, 2009
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Is it accepted practice to include the name of a healthcare provider in the medical chart as long as the provider's role in a patient’s care also is documented?
Anita
When documenting patient care, it is essential to be complete and accurate in your documentation. If another healthcare provider, let's say an LPN, also is involved in the care of your patient and has done an accepted procedure or shared information with you about the patient's overall condition or specific information (e.g., vital signs or something the patient said to the LPN), it is important that the documentation factually reflect to whom the information was shared or by whom care was provided.
If a particular situation is not documented as it occurred, the reader will assume that you, as the healthcare provider documenting in the record, were the one with whom the patient shared his or her information or the one who provided the treatment or assessed the patient’s overall status.
Your facility may have a policy that you use initials and the provider’s role in the care or information received (e.g., JS, RN, or Dr. JS). If that were the case, you would need to follow the facility policy. It is important, however it is done, that a reader of the entry understands who was involved in the patient’s care and the individual practitioners’ roles in that care. This is essential for many reasons, including insurance reimbursement, risk management issues and, if a lawsuit is filed, each practitioner's conduct in the case.
Discussing this issue with your risk manager and your nurse manager will help you gain more insight into documentation in the medical record and the many necessary documentation elements. Reviewing a textbook or an article on this topic also would be helpful.
Cordially,
Nancy
Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.
