Information to Help Mitigate Liability


Risk Management Resources

Risk Management Questions & Answers

What documentation tips can you offer during these unprecedented times?

Adherence to good documentation practices is essential to patient safety and allows healthcare providers to communicate effectively. Reinforce the following practices with providers and staff:
  • Document all communications with patients, regardless of modality, in the medical record. Include the communication of both abnormal and normal test results. When test results require a follow-up action, document the communication of this action and any additional recommendations.
  • Clearly document your clinical decision-making.
  • Document any limitations to your ability to fully assess the patient and what you did based on that. For example:
    • “The exam was limited due to the patient’s need to self-quarantine for COVID-19 symptoms. The patient was examined virtually in a private area. The patient had partial ROM and increased pain. She was instructed to elevate the area, continue with OTC pain medications, and check in with me tomorrow.”
  • If an encounter is conducted virtually, be sure to document not only the encounter but any sites that were linked, the mode of service delivery or technology used, any technical difficulties, and all patient-related electronic communications such as lab/test results. The American Telemedicine Association offers standardized forms that can help providers achieve compliance with documentation.

Do you have any recommendations for timeline documentation to mitigate liability from COVID-19 claims?

How individual organizations respond to the COVID-19 pandemic varies considerably. Multiple factors influence the response. Some of these factors include where you are located, whether or not you experienced a surge, the resources available to you, and when testing became available to you. Given the rapid pace of change and fluctuating mandates/guidance from federal, state, and local agencies, it may be difficult in the future to recollect exactly what you implemented to prevent exposure to COVID-19 and when you implemented it.
  • Consider creating a master timeline of all critical dates and any corresponding documentation. Include:
    • First COVID-19 case diagnosed at facility.
    • Critical communications to staff members and patients.
    • Critical communications or guidance released from federal, state, and local agencies.
    • Federal, state, and local closures and reopenings.
    • All COVID-19 testing.
    • All equipment, capacity, and patient care issues encountered.
    • All staffing changes.
    • The COVID-19 screening questions asked.
    • The COVID-19 precautions implemented.
  • Be sure to maintain any corresponding documentation referenced in the timeline.

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This information is intended to provide general guidelines for risk management. It is not intended and should not be construed as legal or medical advice. Your organization should add to and modify this tool to address the compliance standards and regulations applicable in your state or organization.

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