Strive for Better Documentation

Because it’s Forensic Nurses Week, we’re focusing on ways to improve practice. Today, let’s talk about documentation.

Want to know my one wish for better medical-forensic documentation? Three words: review of systems (ROS). Seriously–hear me out on this.

In order to improve documentation, it’s critical to consider its purpose. We don’t document our encounters in anticipation of trial. We document because it’s the standard of practice for any healthcare encounter, forensic or not. We document because we aren’t going to be the last person to care for this patient. Everyone benefits from picking up where the last guy left off rather than starting from scratch each time (an argument for why medical-forensic records should be available to other healthcare providers, but that’s another post).

So why am I so enamored with ROS? Because it forces us to think about the entire patient, not just the most likely sites of injury or the areas that get swabbed; because it allows us to consider concomitant health issues with which our patients present, ones we can address while they’re with us.* And since we were talking about differential diagnoses yesterday, let’s keep in mind that completing a ROS with every patient often allows us to better identify the most likely causes for the patients’ findings.

Why do I like to see it in records I review before trial? Because it’s harder to argue that the treating clinician is just a forensic technician or arm of the investigation when there is this type of comprehensive exam documented. It demonstrates a commitment to caring for the whole patient and not just focusing on where potential evidence may be found. I have no hard science to back this up, but my anecdotal experience is that programs that don’t conduct (and document) ROS with their patients are more likely to have other gaps in their exam process and documentation: missing vitals, health history, allergy information, suicide assessment, danger assessment, follow-up recommendations. Conducting a ROS means clinicians are more likely to subscribe to the notion that experiencing violence is a healthcare crisis, not just a crime.

Tomorrow, let’s talk about the one process program managers can implement to move our practices forward.

*Many of my patients don’t regularly access healthcare services, so it’s a shame to waste the opportunity to provide as much care as I am able to, simply from a public health perspective.

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