Français

Documentation


Document, document, document!

When to document


It is best to document events as soon as possible following the event (contemporaneous). This is because memory about details tends to fade with time, other events may occur, and there may be disputes concerning their sequence. For example, it may later be important to know if certain symptoms or findings were present before or only after a particular caregiver's intervention.

Case: Delay in documentation
Male physician pushing female patient in wheelchair

Background

A patient is discharged from hospital. The discharge summary is not completed before the patient is re-admitted under the same physician. This second admission is prolonged and complicated by several intercurrent illnesses and events, ending in death.

When the physician completes the discharge summaries for both events, laboratory findings from the second admission are included in the summary for the first.

Think about it

How might this discharge summary compromise the physician?

Outcome

At a subsequent mortality review, there was an inference of delay in responding to these results, with delayed diagnosis and treatment.

Only after detailed review of both admissions was the true sequence of events established.

Lessons learned

Delay in documentation can result in uncertainty about what actions have already been taken, with potential negative consequences for both patients and providers.
Previous
Next