Disaster documentation for the clinician.
Documentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how? In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls.
Los Angeles County Emergency Medical Services Agency, Los Angeles, California and University of Hawai'i Office of Public Health Studies, John A. Burns School of Medicine, USA.
Richard M
RM
Zoraster
Christopher M
CM
Burkle
D004190:Disasters; D004282:Documentation; D057286:Electronic Health Records; D006801:Humans; D007258:Informed Consent; D016365:Liability, Legal; D008499:Medical Records