Senior living providers, their insurers, and counsel who represent them understand that quality medical record documentation is critical in deterring survey citations, combatting predatory plaintiffs’ lawyers, and most importantly improving healthcare outcomes for residents.  High quality medical record documentation also allows providers to contain the cost of claims and litigation through early dispute resolution.  The challenge, particularly in the current staffing environment, is ensuring quality documentation through training and auditing.

Claims Volume and Costs

The CNA Aging Service Claim Report (11^th Edition, 2022) analyzed data collected on CNA insureds between January 1, 2018, and December 31, 2020.  Of note, the report does not address the nonmonetary impact of claims (e.g., staff time redirected to retrieving and reviewing records rather than patient care) and excludes claims less than $10,000.  In 2021, the average cost of assisted living claims ($267,174) exceeded skilled nursing facility claims ($245,559).  Independent living claims, while low in volume, have increased in the average total incurred ($254,606).  One reason for the increased dollar amounts could be there is typically less documentation in assisted living and independent living than in skilled nursing settings, resulting in less data on which to base a defense.

Falls are the most frequent allegation in both assisted living (54.8%) and skilled nursing (36.1%).  The average total amount incurred due to falls increased between 2018 and 2021 across all facility categories, with the overall average rising over 17.5% from $193,236 to $227,199.  Training in comprehensive charting surrounding falls is clearly an area on which to focus.

Quality Clinical Documentation, Audits, and Risk Assessment

If you are a healthcare provider, or provide training or counsel for healthcare providers, implementing strategic documentation practices facilitates vigorous defense of claims or suits.  If you are involved in compliance, risk management, or guidance for healthcare professionals, you can minimize the risk of citations and suits by being proactive in identifying opportunities for improvement through a chart auditing program.

How is quality documentation assessed?  While documentation guidelines vary by state and type of facility, basic tenets apply across the board, including, but not limited to, a determination if the records are:

• Present
• Legible
• Clear/precise
• Complete
• Timely

Conducting proactive and periodic audits on a sample of medical records ensures that staff are complying with policies and procedures and identifies training needs.  Examples of common areas for documentation improvement include the following:

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Employing ongoing documentation training and auditing programs allows providers to be in an advantageous position if faced with a claim or lawsuit.  Ensuring that the medical record documentation is thorough facilitates reduced costs through early case assessment and resolution.

Excelas would be pleased to assist you with efficient and cost-effective training, organization, auditing, early case assessment, medical chronologies, case summaries, and other tasks to allow your team to focus on high-quality care and services for residents, leadership, legal strategy, business development, client relationships, and other critical business initiatives.