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Number 4: Documentation

In the practice of medicine, the general rule is, if it is not documented – it was not done.

DOCUMENTATION DO’S

• Be sure your documentation is timely, complete and accurate
• Write legibly; document clear and concise data
• Document comparison exams and follow up test results
• Chart what you report to other healthcare professionals, regarding the patient test results
• Document your observations of the patient’s condition
• Chart the patient’s issues and concerns
• Chart instructions and responses exchanged with patient and family

DOCUMENTATION DON’TS

• Do not wait to chart documentation at the end of the day, when your recall of the exam findings may be vague
• Never alter a medical record. All medical records are considered legal documents. If you make an error, you must cross it out and initial it. Do not erase or obliterate a medical record.
• Do not document findings that another sonographer reports to you
• Do not document findings that are not true
• Do not use pencil, always document in ink
• Do not use medically unacceptable abbreviations
• Do not sign anyone else’s name to the report

Failure to document and maintain complete and accurate records can open the vascular technologist and the vascular laboratory to multiple vulnerabilities, related to medical mal-practice lawsuits. Documentation provides proof that, indeed, the medical professionals did the right thing. All things being equal, the jury members are generally more inclined to believe defendant testimony when it is supported by a comprehensive chart. For the required characteristics of interpretations, preliminary and final reports, refer to Section 4 of The ICAVL Standards, Part I: Vascular Operations – Organization.

While the litigious nature of our society is certainly negative, the practices, including compliance with The ICAVL Standards, that provide vascular technologists with defense against potential medical malpractice claims are beneficial as they enhance the level of patient care provided.

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DEFINITIONS FROM SDMS’ “DIAGNOSTIC ULTRASOUND CLINICAL PRACTICE STANDARDS”
General Supervision: the minimal level of physician supervision; physician is not required to be present in the office suite when the ultrasound procedure is performed.
Direct Supervision: physician must be present in the office suite when ultrasound exam or vascular procedure is performed
Expected Outcome: The expected information and data which was anticipated to have resulted from the examination.
Expections: Any elements of the examination protocol that were not performed; the Diagnostic Ultrasound Professional must document exceptions in the written summary of examination findings.
Standards: Statements of the minimum behavioral or performance levels that are acceptable. Something established by authority as a rule for the measure of quantity or quality.
Policies: Written statements indicating what actions are to be taken when specific criteria are encountered. A definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions.
Procedures: Written guidelines that state how a task is to be accomplished, the specific steps to be taken, or how a policy is to be executed.

REFERENCES

HPSO.com
Healthcare Providers Service Organization

Medicalmalpractice.com

mbr-law.com

Scope of Practice for the Diagnostic Ultrasound Professional as published by the Society of Diagnostic Medical Sonography

Sonoworldeurope.com

SVU Code of Ethics as published by the Society of Vascular Ultrasound

Would Your Vascular Laboratory Stand Up In Court?
Claudia Rumwell, RN, RVT, FSVT
Micky McPharlin, RN, RVT, FSVT
St. Johns Symposium 3-03