August 07, 2005

Random Bits Learned From The IDR Process

First, if you are doing your own IDR rebuttal, make sure that every page from a resident's chart (even if it is a back page) has the resident's name and a date on it. Second, make sure the names and dates are legible.

Many times, a facility's defense to treatment issues is the fact that the resident or responsible family members refused treatment or diagnostic tests. This defense will not fly unless you are able to demonstrate informed consent on the part of the resident or responsible family members. Thus, if the resident refuses labs that may, for instance, detect problems with dehydration--it is important that the physician clearly informs the resident or family members of the risks of refusing such labs.

If you are trying to administer medication , and he says "I don't want it", inform him of the possible consequences of not taking is medication. Then document the chart with the information and his response.

If you don't have this sort of information in the chart, you won't win on this issue.