About Documentation Errors

The most powerful communication and risk management tool is proper medical record documentation. Creating and maintaining complete and accurate records facilitates greater continuity of care between health care providers and alleviates worry of liability in the event of a claim.

Poor documentation alone will not generally send a patient to an attorney, but could lead to a suit once the attorney sees the records. Poor documentation also makes the case more difficult to defend.

What would your medical records look like to another physician, a plaintiff’s attorney, or a jury? Poor documentation practices can delay care and may signal to others that you are careless or do not care to follow your patients closely.

In addition to potential liability issues, medical boards can discipline physicians if their medical records are incomplete or illegible. Make sure your documentation — including electronic templates — includes your state medical board’s required elements: the reason for the encounter; the relevant history; the physical exam findings; prior diagnostic test results; and the patient’s progress, including response to treatment or change in diagnosis.

‍
EHR templates

A common problem area for physicians involves the use of electronic templates within the electronic health record (EHR). The use of templates is widespread and can save the physician time in documentation. But using templates can also create the impression that the notes are incomplete or inaccurate

When using pre-formatted text or templates, edit entries to ensure the record accurately reflects the care delivered. Inconsistent information in the record, due to pre-populated text, can be problematic in the event of a claim or board action.

It is also important to update each encounter note to reflect the patient’s current symptoms and to check for unintended system defaults to “normal” or “negative.” The review of systems or exam should not conflict with the history of present illness or chief complaint.

Alterations

Another documentation practice to avoid involves “correcting” medical records after an unexpected outcome or notice of a claim. Altering the medical record after the event — even if you believe the information will assist in your defense — is detrimental.

An addendum to the medical record may be allowed if done in a timely manner and clearly identified as such. Include the date and time, a reference to the date and time of the actual encounter, reason for the addendum, the added information, and author’s signature. Also, any changes made in an EHR will likely be “time stamped” electronically.

‍