Even in times of crisis, it is important to consider what is being recorded in the medical record.  Consider these COVID-19 charting principles when accurately charting your care: Paper or Electronic Methods: Your system may have a plan to potentially move to temporary/emergency paper charting during times of extreme surge. This is an acceptable method when necessary.
  • 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.
Ethics Consults/Scarce Resource Allocation:  Within some systems a template ethics consult has been developed and will be used by physicians from the ethics team on allocation of resources, using national standards for prioritizing resources on a scoring basis.  These consults are not intended to substitute your medical judgment, and rather, are a needed, sometimes difficult, administrative function of the organization to fairly allocate scarce resources in times of crisis. Some systems WILL include these consults in the medical record.
  • 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.
Risk Avoidance Tips:
  • 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.
Kyle N. Sweet, J.D. Sweet Law Firm, Managing Partner Thank you to  Jason S. Lees, MD, FACS, Vice Chair of Academic Affairs and Residency Program Director and Professor Department of Surgery, and Heather McClure, JD, LLM, Chief Risk Officer, OU Medicine, both at the University of Oklahoma Health Sciences Center, for their contributions Click here to download this release as a PDF

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