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Documenting Unanticipated Outcomes: An Essential Part of the Disclosure Process

Documenting Unanticipated Outcomes: An Essential Part of the Disclosure Process

Documentation is a critical aspect of healthcare delivery because it memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of a legal action. Documentation also serves an essential role in the disclosure of unanticipated outcomes, such as medical errors, system errors, or other situations that lead to patient harm.

As part of the disclosure process, an appropriate member of the healthcare team should document the unanticipated outcome in the patient's health record, including an objective summary of the pertinent clinical facts surrounding the event. These findings might include the patient's condition immediately before and after the event, subsequent treatment, and the patient's response to treatment. The disclosure conversation also should be documented in the patient's health record, including:

  • Time, date, and place that the conversation occurs
  • The information that is communicated to the patient/family
  • The patient's/family's understanding, any questions they ask or information they want clarified, and any responses provided to questions
  • Names of those present for the disclosure conversation, and who will be responsible for follow-up communication with the patient/family
  • Next steps for patient treatment, care, and communication
  • A notation that disclosure was based on information available at the time of the conversation with the patient/family

Documentation should be completed as soon as possible following the unanticipated outcome and updated accordingly as new information becomes available. For more information about the disclosure process, see MedPro's guideline titled, Disclosure of Unanticipated Outcomes. For more strategies related to documentation, take advantage of two free MedPro checklists: Documentation Essentials and Electronic Documentation.

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