COVID-19 Charting Principles
- Understand your responsibilities in entering the information into the paper, then later electronic, record.
- Understand the plan regarding timing of “late” entries into the electronic record, and how to accurately record events that occurred.
- Understand your billing compliance department’s rules (even if temporary/emergency) on timing of entries and their impact on ability to bill for your services.
- Understand whether your system has plans for scarce resource allocation consults, and what will appear in the record by whom. While you will not be responsible for having resources you do not have, you will be responsible for practicing medicine in the rapidly changing environment, no matter what resources exist. Some states will provide for limited immunity during this time, some will not. Either way, you will only be held to practicing according to the standard of care correlating to this specific time, not the “ideal” world.
- Communicate available resources to patients, and then chart in the medical record, objectively and accurately. Include that the patient had an opportunity to ask questions and had them answered.
- Do not give subjective judgment on resources or lack thereof. Address capacity concerns through administration/risk management, but not in a patient’s medical record.
- Be factual with entire clinical picture and magnitude of co-morbidities. Age or disability is certainly relevant to clinical picture, but must not be the only factor considered, so be accurate in your description of all factors related to prognosis.
- Do not comment on the care provided by others. Only communicate medical facts.
- Do not chart the condition of other specific patients in your patient’s record to justify allocation/standard of care/environmental issues, but should refer to “the crisis” or “surge” or “lack of capacity” in general as appropriate to convey to a future reader the impact of the situation. Simple factual references will suffice.
- Remember social media comments will live on forever and may be discoverable.
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