How to Document When There is an Unexpected Outcome

Document Unexpected Outcome

posted by Kathy Everitt on Tuesday, July 17, 2018

As a general rule, your records should not contain words such as “mistake,” “error” or “inadvertent,” which might lead the reader to a negative conclusion about the care and treatment you rendered. Words are interpreted in so many different ways and context is important. This is especially true when documenting events in your records.

So, when the “unexpected” outcome occurs, immediately – or as soon after the event as possible – document: 

  • The date, time and place of the event
  • The complication or situation
  • A factual account of what happened
  • The identity of people present when the event occurred, including their names and titles 
  • If the primary provider was not present, note the primary provider’s name and time notified
  • The patient’s condition immediately before the event
  • The patient’s condition immediately after the event
  • Your appropriate and aggressive response to treat any complications
  • Any action taken
  • Treatment provided
  • Diagnostic tests ordered/done
  • Consults ordered and referrals made
  • The patient’s responses to the medical intervention
  • A follow-up plan until the condition is resolved:
  • If the patient is released to home, follow up with a phone call (document this action and the patient’s response)
  • Document both positive and negative findings
  • Document conversations with family members/caregivers, including their names and relationship to patient

For assistance from our claims professionals on this topic, please call our Claims Advice Hotline at 800-242-4052. Or learn more about our claims services.

  1. documentation
  2. liability
  3. patient communication
  4. risk management

About The Author

Kathy Everitt

Kathy brings with her more than 30 years of professional liability experience to NCMIC, encompassing underwriting, sales management, as well as risk management consultation services for healthcare professionals. She has earned her CPHRM designation and, as a licensed property/casualty agent, Kath ... read more

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