Billie states:
"My area of concern is our documentation.  It is not part of the
legal
chart.  We keep our records on file in our office.  I've been
wanting to
speak with the hospital attorney about this for awhile.  Maybe I'll
push a
bit harder on this issue.

In the end, I think I have more questions than answers!"

This should be an area of concern.  When we got a supervisor
knowledgable in legal and documentation issues, she was shocked.
Apparantly it is a big "no-no" to have what are referred to as
"shadow charts" within the hospital setting.    We kept our own
records of both inpatient visits (over and above what we did in the
computer chart) and outpatient visits and phone calls.  We were told
this could result in very large fines for EACH one of these sheets!
If it was important enough to write down, it should be in the actual
chart.  Even when we changed our practice and  got rid of the forms
there was a big question of what to do with the existing ones.  We
currently use the forms  only as worksheets which are sent to
Medical Records and discarded once the patient is discharged-we have
to swear that they do not contain any information that does not
eventually get recorded int he chart.

It definitely was more questions than answers at first, and there
are still questions, but we are "safer" legally.

Winnie

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