Importance of Proper Documentation


If a tree falls and no one hears it, did it make a sound? One suggested answer is that it depends on your interpretation of the word ‘sound’.

A similar question can be asked in the world of documentation …lf there is no documentation, did the action occur? Unfortunately, in the legal world, there is little room for interpretation. Savvy plaintiff lawyers will always argue that if there is no documentation, the action did not occur. End of discussion.

Senior living is such a “caring” business, and we know you and your staff do many wonderful things every day to show your care for your residents, however, many times these things are done with little thought or regard for documenting what you have done. Having spent 20+ years in Senior Living Operations, I know first-hand how often care staff go above and beyond in providing compassionate care and treatments that simply go undocumented for a variety of reasons including: documentation by exception only; lack of time; lack of staff; inadequately trained staff. All understandable reasons. Unfortunately, as a Risk Manager, I now review countless examples of Senior Living claims/lawsuits that prey on the sparse documentation found in the typical resident file.

There are many challenges to correct documentation however the “we’re a social model, not a medical model” or documentation by exception or “our state doesn’t require this” no longer affords your facility a viable defense. The fundamentals and standard best practices for documentation must always be followed to protect your facility and employees as well as your residents.

As a rule, documentation should be objective, complete, accurate and timely. Just the facts, not the feelings of the clinician should be documented. Documentation should describe symptoms, current condition, communication with responsible party, physician and response to any interventions or treatments provided by facility.

Standard best practices dictate that Senior Living providers should document the following at a minimum:

  • Pre-Move Assessment. This is used to determine overall health and appropriateness for admission. Assessment should include Physician Statement/Attestation in addition to internal nursing head to toes assessment which includes a comprehensive Falls Screening Tool.
  • Subsequent Assessments. These Internal Assessments should be completed:
    • With each Hospitalization.
    • Quarterly for all residents with the following diagnosis: Alzheimer’s, Dementia, Parkinson’s, Diabetes, Congestive Heart Failure; etc.
    • Semi-Annually for the “typical” Assisted Living type resident.
    • Quarterly for all SNF residents.
    • With any significant change in condition.
  • Incident Reports. Comprehensive review of unusual events with or without injury that are documented on the IR. Determine root cause of incident and document interventions provided with their effectiveness and document communication made with Physician and Family Member/Responsible party.
  • Resident Change in Condition. This should include a new assessment and Falls Screening along with updates to Plan of Care.
  • Medication. Ongoing list of current resident Medication and any changes made to treatment plan.
  • Weekly Skin Assessments. These are typically performed during bath/shower or ADL time.
  • Coordination of Care with Outside Providers. Typically refers to Physicians, Home Health Care Nurses and Therapists, Hospice Nurses. Should document all conversations regarding resident treatments and obtain copy of progress notes, plan of treatments when possible.
  • Training of Staff. This should include documentation of orientation, weekly, monthly in-services of staff and annual refresher classes with employee signed acknowledgement. (Can be either Electronic or Paper or a combination of both.)
  • Documentation of Resident Care Discussions. Communication of individual care items, incidents, etc., with resident/family/responsible parties even though it may appear small, slight, or quick. Remember, if it is not documented it did not happen.
  • Resident Agreement. Also referred to as Resident Move in Agreement, should be signed by all residents and/or responsible parties, prior to resident admission. The Agreement should include an Arbitration Agreement where allowed.

What to document and what to include in staff training:

  • Observations
  • Daily Measurements
  • Safety issues
  • Resident Statements and Complaints
  • Unusual Events, resident refusals of care, medications (Incident Reports?)
  • Weight
  • Vital Signs (blood pressure, pulse, and temperature)
  • Food Intake
  • Fluid Intake
  • Sleeping Pattern
  • Bathing pattern
  • Walking record
  • Toileting
  • Regular skin checks

What kind of charting? Paper or Electronic Health Record (EHR) or both?

  • Electronic Health Record. (Or EHR) Is set up to ensure that medical charts are complete and accurate. Think of it as a digital version of a resident’s paper medical chart. With good EHR software and EHR systems, health care providers will be alerted to any missing, incomplete, or Inaccurate medical charts.

An EHR is a real-time record that makes health information available instantly and securely to authorized users. EHRs are built to share medical notes with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and workplace clinics – so they contain information from all involved in a resident’s care. This has the potential to automate and streamline health provider workflow.

The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting. An EHR also guarantees a resident’s medical chart is never lost and stored in one easy to access location.

Compared to paper records, the use of EHRs can improve resident care tremendously. They can:

  • Reduce the incidence of medical error by improving the accuracy and clarity of medical records and coordination of diagnosis and treatment among health providers
  • Make the health information instantly accessible, reducing duplication of tests, reducing delays in treatment, and residents well informed to take better decisions.
  • Allow residents/families to log on to their own record to see health trends to be better

informed about their health

  • Paper Health Record. What should be in a resident paper chart? The basics, a binder/folder type with dividers for sections including face sheet/demographics, advanced directives, H&P, Assessments, Care Plan/Service Plan, Medication Records, Social Services/ Activities, Physician orders/ notes, Lab, Home Health, Therapy, Progress notes.

Who is watching the data and responding? Monitoring the documentation through Chart Audits routinely provides a comprehensive picture of the resident at all times and allows the community to stay ahead of any potential issues prior to them happening. This can be the responsibility of the Administrator, DON, or ED, individually or as a team approach.

Senior living is such a “caring” business that many times things are done with little thought and regards to documenting all the great things that you and your staff do every day to “care” about and care for the residents.

Replying to State’s Statement of Deficiencies {SOD). It’s important to remember that this becomes a public record and is often referenced by plaintiffs’ attorneys. The Plan of Correction (POC) should clearly define the corrective action taken and preventative measures to ensure continued compliance in the future.

When to Report a Claim to your Insurance Carrier? Things do not always go as planned and when an unfortunate incident takes place that causes harm to a resident and the family is irate and/or has expressed potential litigation or requested medical records, it’s time to notify your Carrier. As a reminder, the quicker you inform your Insurance Carrier to a “potential” claim the faster we can assist with investigation and advise on resolution options.