Strategies for Accurately Completing Residents' Medical Records

The accuracy of a long-term care facility's medical records system requires effective training, ongoing education, and great communication among the staff that handle the records. Staff need to be constantly aware of issues that could impinge on that accuracy and have strategies in place to ensure they have adequate time to document all events that occur-from a fall to a prescription drug reaction to weight gain or loss.

Some of the issues that may prevent accurate documentation include:

Staffing shortages. A facility must have an adequate resident to nursing staff ratio in order to operate effectively. When staff is short, the nurses and aides left to take care of the residents often do not have adequate time to accurately complete a resident's medical record or file an incident report.

An effective facility would have an on-call roster of nurses and aides to fill in should any nursing staff call in sick or have an emergency. Establishing good communication and relationships among the nursing staff would also help to mitigate scheduling issues. If a nurse or aide needed a day or afternoon off to handle an emergency or had become ill and could not work, the staff could work it out among themselves to fill in for one another.

Inadequate storage area. Paper medical records can become bent, torn, or damaged by liquids if the facility does not provide a secure, clean area for storage and documentation of records. For instance, if the records are stored in a closet with insufficient storage for all of the files, the files can become damaged as they are shoved in and out of a cr`mped space. Or if the nursing staff does not have adequate desk space to complete the records, they may spill coffee or liquids on the files. Having the proper storage space and clean, dry surfaces for writing is important to minimize this issue.

Computers crashing. As medical records are becoming automated on a universal scale, many long-term care facilities are implementing computerized medical record systems. Training and on-going education is instrumental in effectively implementing such a system, but what happens when the system goes down? The facility must have an IT person available, or at least a help desk to call, to help resolve a computer problem and get the system working as soon as possible. The facility must also have a temporary procedure for completing paperwork for the resident's medical record if the computer issue takes a while to resolve.

Article Source: Denise L Wittkofski

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