Question

A patient's chart has been subpoenaed for pending malpractice litigation. In preparing the chart, you discover an error that was made when the results of the laboratory report were incorrectly documented in the chart. You have the original laboratory report. What should you do?

3. Identify the steps you might take in inspecting a patients paper chart before filing reports or other patient information. Or if the clinic uses electronic medical records (EMR) what would you check before scanning a report or other information into their EMR.

Answer 1

In case of subpoenaed documents, no one have the authority to view the documents.It is illegal.You can view and discover the mistakes only if you are granted permission legally.Suppose if with proper permission you are discovering the mistake then you must reveal it to the authorized person.you should not make changes or correction in the document as it is a subpoenaed issue inform about the mistake to your superior one.

3.Check the patient name,room number or bed number and identification number.

Check whether all the orders done timely.

Check whether any unfilled documentation present.

Check that all medications till to that time given and signed by the nurse who gave the medicine.

Check if pending work present.

While filling report such as lab reports check the date and cross check it with the client name and identification number to avoid error in filling or scanning lab reports.

After all these checking make documentation or fill the reports.These steps helps to avoid error and allows the work in organised and efficient way.