Disclosure Documentation
Disclosure of Harm
Disclosure of harm refers to a required process involving open discussions between a patient and healthcare providers about events leading to patient harm, the harm itself, and plans for future care. The associated patient and/or family conversations are both immediate and ongoing.
Immediate disclosure conversations should occur within 24 hours after a clinical adverse event (see AHS Disclosure of Harm Procedure) and be documented in the patient’s Connect Care record.
Ongoing disclosure discussions may be appropriate and should also be documented in Connect Care.
Documentation of disclosure should be completed by the person who leads the disclosure conversation (e.g., nurses, physicians, allied health, managers, leaders, or other clinicians). Other disclosure leads without the necessary documentation access should ensure that an enabled member of the disclosure team is assigned to document discussion(s).
Disclosure documentation can be inserted into a progress note using a SmartLink (".DISCLOSUREHARM"). A disclosure document can be quickly generated from any Letter Forms link under the category of "Chart Access".
Reporting Adverse Events
It is important to report clinical adverse events using the “Reporting & Learning System for Patient Safety (RLS).” This is easily found by doing a chart (global) search for “RLS.”