How important is it to make sure the time and date are accurately entered into the record?
Consider a claim that occurred decades ago in a hospital in the northeastern United States involving a code that was called in the operating room at 11 p.m. At that point, all personnel in the operating room (OR) were working diligently to save the patient; yet nobody was actually recording the timing of the events. At 11:15 p.m., a nurse entered the OR and began to record the time and date of the actions of the resuscitation team. The problem was that this document was labeled “11:15 p.m. – code began.”
“When an order is entered into the medical record by a healthcare provider, it’s absolutely essential that the date and time of that order be recorded as well. With today’s electronic medical record (EMR), it’s easy to simply not worry about recording the date and time and assume that ‘the machine will do that for me.’ However, my reading of recent literature shows that as many as 70 percent of individual physician offices haven’t yet switched to an EMR.” –Timothy R. Bone, president of Florida-based MedMal Direct Insurance.
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After the OR event had concluded, the healthcare providers involved in the resuscitation sat down to complete the written record. What document did they use to refresh their memory? Yep, the one labeled “11:15 p.m. – code began.” They thought the code started earlier, but since this document showed 11:15 p.m., they assumed it was correct and just filled normal values in the written record between 11 and 11:15 p.m. They were tired; it was the end of the shift. Paperwork needed to be completed.
“When an order is entered into the medical record by a healthcare provider, it’s absolutely essential that the date and time of that order be recorded as well,” said Timothy R. Bone, president of Florida-based MedMal Direct Insurance. “With today’s electronic medical record (EMR), it’s easy to simply not worry about recording the date and time and assume that ‘the machine will do that for me.’ However, my reading of recent literature shows that as many as 70 percent of individual physician offices haven’t yet switched to an EMR. Parenthetically, the primary reason stated for not switching is that it’s expensive and doesn’t improve patient outcomes.”
And even if medical practices are now using an EMR, are physicians and practice managers willing to trust the technology 100 percent to accurately record the date and time of this life-saving treatment that healthcare providers are now entering into the record?
“Have you accessed your landline voice mail lately,” Bone pointed out, “and noticed the accuracy of the time the machine says the message was left?”
To assure that orders are entered into the medical record adequately dated and timed, Bone recommended this review procedure:
Obtain a sample of 50 records of recently seen clinic patients or recently discharged hospital patients and analyze the first three orders entered in each for the presence or absence of the date and the hour of day.
Calculate the appropriate percentage for each category of those orders with and without dates and those with and without times.
“If all is in order, notify the Medical Executive Committee and the medical staff at the next staff meeting,” said Bone. “If problems exist, devise a solution, implement it, and re-audit the issue after approximately six months. Report the results of your re-audit to the Medical Executive Committee and medical staff.”
So what happened to the family of the patient who died? Months later, when the family hired an attorney to read the record, it appeared that medical negligence had occurred. How could the patient’s health have so rapidly deteriorated from 11 to 11:15 p.m. without anybody appearing to have treated the problem? But it wasn’t negligence; rather, it was simply an incorrect entry in the record of the time and date the code began.
“The case was resolved successfully and dismissed, but not before many dollars had been spent in legal fees,” said Bone, “and healthcare providers had experienced much angst.”
Editor’s Note: This article marks the twelfth in a risk management series with Timothy R. Bone, president of Florida-based MedMal Direct Insurance. Florida Medical News addresses some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method. This process includes providing an “outcome goal” or objective, and then offering a relatively simple approach to data-gathering via chart review, observations, or simple surveys. The series flows from the following known fact: as much as 80 percent of all medical malpractice lawsuits are generated from non-clinical issues in the practice of medicine.
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