Documentation

Risk – Documentation that is incomplete or inaccurate impacts quality resident care and can create legal, financial, regulatory/licensure and reputational risk.

Risk Management Strategies (Documentation of a Significant Resident Event):

  • Document the Facts – Document accurate information about the event, including assessment, monitoring, interventions, actions, communications, and resident response. Include relevant comments from the resident and family regarding the event (e.g., “My family brought my new glasses yesterday. I have been having balance issues since I started wearing my new glasses”).

  • Timeline of Care – Document the timeline of care and treatment during and after a significant adverse event including communication and requesting an ambulance (as appropriate). Documentation should include vital signs, acute symptom management (e.g., complaints of shortness of breath or difficulty breathing after a fall), and pain management. Document the transition of care if the resident is transferred to the emergency room or an acute care facility, including hand-off report to the accepting nurse.

  • Clear, Concise, Complete – Ensure that documentation regarding the event is factual, concise, and complete. Avoid assumptions, opinions or accusations about the care and treatment. Do not blame or criticize the resident, family, other care team members, the facility, or other healthcare organizations.

  • Communication – Clearly document communication with the primary care physician, the resident (as appropriate), and the family (as appropriate). Assign responsibility for post-event follow-up communication with the resident and family.

  • Interventions – Ensure an updated assessment of risk is conducted after an event (e.g., fall risk, skin integrity risk, elopement risk). Current interventions should be evaluated for effectiveness and new interventions implemented to manage the risk (e.g., physical therapy assessment). Update the resident’s care/service plan.