To Document… or Not to Document: Charting in the Correctional Healthcare Setting

Written by: Beth Boone, Esq.

Healthcare providers in the correctional setting face many unique challenges while providing care to individuals being detained or in the custody of the government. Chronically ill patients, historically non-compliant populations, mental health problems, drug and alcohol issues and communicable diseases all interplay with treatment. When interacting with nurses, physicians, dentists and mental health professionals in this industry, the age old questions about documentation always arises. If I didn’t see it should I document it happened? If I am relying on what the patient told me do I somehow indicate that it is hearsay? Should I document “allegedly” or independently verify with the correctional officers? Some reminders about charting may be useful.Healthcare providers in the correctional setting face many unique challenges while providing care to individuals being detained or in the custody of the government. Chronically ill patients, historically non-compliant populations, mental health problems, drug and alcohol issues and communicable diseases all interplay with treatment. When interacting with nurses, physicians, dentists and mental health professionals in this industry, the age old questions about documentation always arises. If I didn’t see it should I document it happened? If I am relying on what the patient told me do I somehow indicate that it is hearsay? Should I document “allegedly” or independently verify with the correctional officers? Some reminders about charting may be useful.

PRE-PRINTED FORMS

If there is a form, use it and complete it. If not completing the same,  at least chart why you are NOT completing a certain section. In other words, you may not remember two years after the care and treatment why you left the section about medications blank, or the medication refusal form you had the inmate sign is missing from the chart. If you clearly chart on the medication section of that the PATIENT REFUSED, and can also show a medication refusal form executed by that patient, it becomes crystal clear. Additionally, the medical chart needs to clearly reference all healthcare interactions, as reliance on jail or prison records or communication kiosks and internal systems may not provide a clear or accurate healthcare picture.

OBJECTIVE NOTATIONS

You probably did NOT see the fall alleged to have occurred, or how the actual injury occurred that the detainee alleges happened. However, chart and document as you would a patient on the “outside”- i.e. patient reports that she fell while stepping from shower. Even if you are concerned that there may be litigation in the future over a certain incident, using terms like “hearsay” and “allegedly” while charting will probably provide more headache in the litigation. In other words, it appears that you lawyered up instead of focusing on a thorough assessment of complaints. If you have doubts that the injury occurred or doubts regarding that inmate’s specific complaints, use objective notations and examples to illustrate the same. As an example, a physical therapist may note “limited range of neck movement noted upon exam” but also notes that the same symptoms did not appear to be exhibited with movement while walking.

PROTOCOLS

If you are using a protocol for a specific situation, document the use of the protocol, read it and note ANY areas in which protocol differs from actual treatment provided. In other words, any variations from that protocol need to be clearly noted, preferably dated with a time, and the reason that the protocol was edited, revised or altered. May make complete sense at the time, but time may make the reason less memorable unless documented!