MEDICAL RECORD DOCUMENTATION REVIEW—ARE YOU PROTECTED?

October 29, 2017

Texas Pain Society

9th Annual Scientific Meeting

Presented by:

Ken Braxton, Jr., J.D

Texas Health ResourcesDallas, Texas

The material and information presented in this seminar are intended for educational and informationalpurposes only. The materials and information are not intended to provide legal advice.

Documentation Goals

• Provide accurate and complete information about care/treatment

• Provide basis for planning course of treatment

• Legal documentation to substantiate care provided-Pain Contract (attached)

• Provide ongoing means of communication between care givers

Litigation review will focus on the following questions:

Is the record consistent with the patient’s allegations?

Does the record clearly show that a reasonable decision-making process occurred before the course of treatment at issue was selected (Pain Management Plan/Contract)?

Did the clinician collect the appropriate diagnostic data and correctly interpret it?

Are there any significant inconsistencies between entries made by the PCP vs the Pain Management consultant regarding the patient’s condition?

Is the record legible, comprehensive, and neat or would it make a poor impression on a jury?

Do the dates of procedure reports and the discharge summary indicate they were completed in a timely fashion?

Documentation (notice the trend)

• Makes or breaks the case

• Dates/Times

• Be concise but thorough

• Discussions about treatment options

• Vitals and Pain levels on admit/discharge from Day surgery

• Discharge instructions

• Handing off to Referring provider

CASE STUDIES

Recent Closed Claims

Pain Management

Agreement

Questions?

THE END