Medical Documentation

A self-evident concern that cannot be over-emphasized is the value of pertinent documentation. A correctional healthcare program lives and dies by its documentation.

In addition to being provided in a highly litigious environment, correctional healthcare is also closely scrutinized and regulated by outside agencies with an active interest in the content of your facility’s medical records.

Healthcare providers should be encouraged to think prospectively and presume that their actions (or decisions not to act) will be challenged legally and openly criticized before regulatory agencies such as the Department of Health.

The provider notes should thus not reflect an emotional state toward the offender through the use of editorial comments or exclamation points. Nonetheless, the notes should at the same time document the offender’s affect ("patient laughs and smiles") and collateral activity ("patient able to remove shirt unassisted without difficulty"). The healthcare provider should also note what isn’t a problem or what is absent from the clinical picture ("no edema, discoloration or deformity noted").

Since 1986 I have researched hundreds of offender medical issues through in-depth medical documentation reviews and can show you where your healthcare records may be working against you.