CME: Avoiding common documentation errors

CME: Avoiding common documentation errors

by Wayne Wenske, Senior Marketing Strategist 

with additional material by Tanya Babitch, Assistant Vice President, Risk Management

Objectives‍

Upon completion of this educational activity, the participant will be able to:

• describe good medical record documentation practices;
• summarize how to avoid common documentation errors;
• discuss the unique documentation risks associated with using electronic health records; and
• define the recommended components of documentation policies and protocol. 

Course author

Wayne Wenske is Senior Marketing Strategist at Texas Medical Liability Trust (TMLT).

Disclosure

Wayne Wenske has no relevant financial relationship(s) with ineligible companies to disclose. TMLT staff, planners, and reviewers have no relevant financial relationship(s) with ineligible companies to disclose. 

Target audience

This 1-hour activity is intended for physicians of all specialties who are interested in learning more about establishing and maintaining quality patient records and avoiding common documentation errors.

CME credit statement

Texas Medical Liability Trust is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. 

Texas Medical Liability Trust designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Ethics credit statement

This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.

Test

To receive CME credit, physicians should complete the test questions that follow the activity. A passing score of 70% or better earns the physician 1 CME credit.

Pricing

The following fee will be charged when accessing this CME course online at http://tmlt.inreachce.com. 

Policyholders: $10

Non-policyholders: $75

Instructions

CME test and evaluation forms must be completed online. After reading the article, go to http://tmlt.inreachce.com. Log in using your myPortal account information to take the course. Follow the online instructions to complete the forms and download your certificate. To create a myPortal account, go to www.tmlt.org, click the log in button, and follow the on-screen instructions.

Release/review date

This activity is released on March 15, 2024 and will expire on March 15, 2027. Please note that this CME activity does not meet TMLT’s discount criteria. Physicians completing this CME activity will not receive a premium discount

Introduction

A basic tenet of health care risk management is the importance of producing and maintaining clear, comprehensive, and up-to-date patient records. A patient’s medical history; family and social information; relevant clinical findings; treatment plans; procedures; medications; observations; conversations; diagnoses; and follow up are all important components of documentation. 

Documentation also improves communication between patients and their caregivers and among caregivers. Maintaining a high standard of documentation—and thus communication—increases the quality and continuity of patient care.

The patient record can also help to demonstrate that the standard of care was upheld from a legal standpoint. Medical boards and regulatory agencies may use medical record documentation to determine a physician’s compliance with state, local, or hospital quality of care standards.

Poor medical documentation can lead to treatment errors, medication errors, and procedural or surgical errors. Adverse consequences of poor documentation can also include:

• unnecessary, expensive diagnostic testing;
• unclear communication among the health care team, which can lead to further errors; and
• inaccurate information provided to the patient during an informed consent conversation.

In a malpractice claim, what’s found (or not found) in the medical record will be paramount to the case. Therefore, accurate, legible, and complete documentation is often a physician’s best defense when confronted with a claim or medical board action. 

This article will review what constitutes a poor vs. quality patient record; how to avoid common documentation errors; and risk management considerations when using electronic health records (EHRs) and scribes. 

What does good documentation look like?

At minimum, an individual patient’s demographics should be included in their record, including:

• full legal name;
• birthdate/age;
• biological sex assigned at birth;
• gender and/or gender identity;
• ethnicity;
• contact information, including address;
• race;
• marital status;
• education level; 
• medical insurance information; and 
• profession or employer.

This information should be updated when applicable and patients should be regularly asked if their information on file is correct. Collecting patient demographics helps to confirm a patient’s identity, facilitates strong communication, ensures correct billing, and helps flag health risks and other factors that may affect a patient’s care. (1)

For example, if a patient’s address is in an area with limited access to healthy or affordable food (a “food desert”), they may be at greater risk for nutritional deficiencies, obesity, being underweight, cardiovascular disease, certain types of cancer, or birth defects. (2)

Additional non-demographic patient information to collect includes:

• reason(s) for current visit (or chief complaint) and relevant history;
• current prescriptions;
• drug allergies; 
• hospitalizations, surgical procedures, and new diagnoses, treatments, or prescriptions from other health care providers if applicable; 
• lab work performed during or before the visit;
• exams performed during the visit and their scope;
• positive findings of the lab work and exams;
• relevant negative findings of the lab work and exams;
• key abnormal test findings;
• assessment, clinical impression, or diagnosis;
• reasoning or rationale behind diagnosis;
• clear treatment and management plan;
• informed consent or agreed upon actions with patient;
• future treatment recommendations;
• new administered, prescribed or renewed medications, specifying amount, frequency, number of refills, and dosage;
• education and instructional materials provided to patient and/or family;
• referrals and consultations;
• communications or conversations with patient, patient’s family, and friends; and 
• recommended return visit date. (2, 3)

A patient’s progress, including response to treatment, any change in diagnosis, or non-compliance should also be documented.

Patient information must be added to the record promptly. If there is a delay in documenting any patient or treatment information, the reason for the delay should also be documented. All entries must be dated and accompanied by the name and designation of the person making the entry, and their electronic signature must be included. (2)

The Texas Medical Board also states that “salient records received from another physician or health care provider involved in the care or treatment of the patient shall be maintained as part of the patient's medical records.” If you practice outside of Texas, please refer to your state medical board to determine what constitutes adequate medical documentation in your state. (3)‍

Sidebar: Managing medical records in Texas

Here are answers to common questions about the management, retention, and release of medical records in Texas. These rules are provided by the Texas Medical Board (TMB). 

If you practice outside of Texas, please refer to your state medical board for guidance.

How long do I need to keep medical records?

For adults — all records must be kept for at least seven years from the date of the last treatment. “Keep in mind, ‘treatment’ might include a phone call, a prescription refill, or other contact with the patient.” Hospitals are required to keep records for 10 years, and some physicians may also choose to keep office records for 10 years. (4)

For minors — records for minor patients must be kept for at least seven years from the date of last treatment or until the child turns 21, whichever is longer.

Medical records that relate to any civil, criminal, or administrative proceeding may be destroyed only if the physician knows the proceeding has been finally resolved.

Who “owns” the medical record?

The physical or digital documents are the tangible, personal property of the person or entity that created them. However, by law patients have the right to obtain copies of their medical records. The only clear exception in Texas law is in the Medical Practice Act, which states: “If the physician determines that access to the information would be harmful to the physical, mental or emotional health of the patient.” This guideline is outlined in the TMB rules Chapter 165.2.

The physician might be asked to explain why the records or information may be harmful to the patient. See the next question below for details on what is required when denying records to a patient. Never release the original record, except under subpoena and then retain a copy.

Is there a deadline for providing requested medical records?

Texas law gives a deadline of 15 business days to provide medical records upon receipt of a request and any agreed upon fees. Federal guidelines generally require release within 30 calendar days, so practices should check their state laws and release records within the shortest required timeframe. 

This same deadline also applies if the physician feels it would be harmful to release copies of medical records to a patient. The physician or health care entity has a deadline of 15 business days to provide a written, signed, and dated statement that details the reason for the denial and provides instructions to the requestor on how to file a complaint with the Department of Health and Human Services (HHS) and the TMB. A copy of the denial statement should be placed in the patient’s medical and/or billing records. (3, 4)

Common flaws in patient records — and how to avoid them

A flawed patient record will most likely be unclear, incomplete, or lacking detail. Other common errors are listed below.

1. Omitting important treatment details, such as:
   
   • the patient’s chief concern or reason for scheduling the appointment; 
   • the patient’s vital signs;
   • severity of the condition or symptoms;
   • test results; 
   • concerns or questions raised by the patient; and
   • education materials provided to the patient.
     

Medical documentation should be clear, concise, and detailed enough to describe a patient’s condition and treatments accurately. It is possible to be too brief or ambiguous in the record, which can lead to incorrect diagnoses or treatment decisions or unnecessary testing.

Make sure your notes are specific, objective, consistent, and clearly present a patient’s story. Establish policies and procedures for documentation, including what is required, accepted medical terminology and abbreviations, and medical record review protocol. Any time the policies and procedures are updated, staff members should be required to sign an acknowledgement that they have read and understand the updates.

2. Recent studies have shown that patient records, particularly in EHRs, can become overloaded with excessive notes and data, which can hinder a physician’s ability to make an appropriate diagnosis and treatment plan. “The overload of information stems from copying and pasting into charts, use of templates, excessive alerts, and adding data that are necessary for billing but effectively useless for clinical care.” (5)
   

Focus on the essential documentation requirements of your organization. Again, these requirements should contain the information that is meaningful and relevant to patient care. Developing these protocols may take time, and involve regular, systematic review to ensure the records are comprehensive and compliant without being overly complicated.

3. Failing to document patient informed consent. Failing to obtain and/or document informed consent can make a physician vulnerable to a claim of negligence. In the context of a lawsuit, a plaintiff attorney will likely reference the old adage, “If it is not documented in the patient record, it did not happen.” (6)
   Documenting informed consent occurs after explaining the risks and benefits of a procedure or treatment to the patient and assessing the patient’s comprehension. Apart from a signed consent form, it is recommended that the consent discussion with the patient be included in the records.
   If written consent forms are used, it is important that patients have the opportunity to review the forms and ask questions. Then, obtain the signature of the patient or a patient’s guardian, witness signature, and the date that both parties signed the document.
   If feasible, and dependent on individual state laws and consent form requirements, the physician obtaining informed consent may also sign the consent form. The physician’s signature indicates that he or she fully described the treatment to the patient; that the patient understands the risks and benefits of the treatment; and that the patient consents to the treatment with full knowledge and understanding of the risks involved. Retain all executed informed consent documentation in the patient record.
   
4. Failing to correctly date and sign a patient note. Every note entered into the record should be signed and dated. Make sure documentation includes a digital signature and date. Notes without a date and signature may also cause confusion for other care team members.
   
5. Failing to document phone calls. Every clinical encounter with a patient should be documented in the patient’s file, including phone conversations.
   If a patient calls to ask for clinical advice or help over the phone, the conversation must be documented. The note should include the reason for the call, any advice provided to the patient, the date and time of the call, and the signature of the provider who fielded the call. In the event of an emergency, the caller should be instructed to call 9-1-1 and this advice should be included in the record.
   Your office or organization’s policies and procedures should include guidance on whether a patient phone call requires an appointment, either in person or via telemedicine, or if the call may be addressed immediately over the phone. “It is important to keep in mind that a patient’s phone call could be the last form of communication with your office before a lawsuit is filed.” (7)
   
6. Failing to document a patient’s informed refusal or noncompliance. As with informed consent, it is important to document a patient’s refusal of treatment or noncompliance. “Informed refusal” also includes patients who decline medication, routinely miss office visits, defer diagnostic testing, or refuse hospitalization. Again, failing to thoroughly document this refusal or noncompliance can leave a physician vulnerable to claims of negligence or malpractice. (8)
   

Notes of the discussion with the patient should be included, as well as notes from consultants and specialists, social work providers or organizations, and psychiatry specialty services as needed. These notes should also comment on the patient's mental status and decision-making capacity. Physicians can further protect themselves against claims of negligence or malpractice by having the patient sign the note or a statement that describes the informed refusal.

Documentation of a patient's informed refusal should include:

• description of the intervention offered;
• reasons the intervention was offered;
• potential benefits and risks of the intervention;
• note that the patient has been told of the risks, including possible jeopardy to life or health by refusing the intervention;
• clearly document that the patient has unequivocally and without condition refused the intervention; and
• reason(s) why the patient refused, particularly if the patient's decision was rational and one that could not be overcome. (9)

You may consider establishing an informed refusal form for your office or practice. If a patient's refusal could lead to severe or permanent injury or death, use this form to help you clearly document the refusal. Also, asking a patient or guardian to complete or sign the form may reinforce the seriousness of the situation to an indecisive patient or guardian and help them to reconsider. (9)

7. Failing to remain objective while documenting patient encounters. It is important to record entries using objective language. For example, if a patient is not performing prescribed physical therapy exercises at home, document that the patient is “noncompliant in following home exercise instructions.” Use wording that clearly state the patient’s condition and the care provided, not a subjective opinion.
   Another example would be to not record a patient as being “a drug addict” or “an alcoholic” without objective substantiation of these assertions. Instead, the physician could conclude that the patient “demonstrated drug-seeking behavior” or “had slurred speech.” (10)
   

Subjective opinions that may be interpreted as stereotyping or expressing disapproval can paint the provider as having implicit biases and stigmatize the patient, negatively affecting the quality of the ongoing health care received. 

8. Inadequate or incorrect patient history. Quality patient records often begin with creating a good patient history, including family history, drug allergies; and names of other physicians that the patient is consulting. 
   An effective patient history should include:

• Chief complaint (CC): A concise description of the patient’s major health concern or symptoms that caused the patient to seek care. This includes how long the patient has experienced symptoms and any other pertinent details. The CC is often documented in the patient’s words. For example, “Patient complains of shortness of breath (‘wheezing’ and ‘can’t catch my breath, like I’ve been running’) for three days, worsens upon walking” or “Patient complains of upset stomach, nausea, fatigue and feeling ‘woozy’ for two weeks.”
• History of present illness (HPI): Chronological description of the patient’s illness or condition, described in prose form that conveys the patient’s present condition as a linear narrative.  
• Past medical history (PMH): Patient’s history of major illnesses, surgeries, or chronic conditions provided in a chronological listing:
  
  • major childhood illnesses;
  • adult medical conditions;
  • current medications with dosage, including prescriptions, over-the-counter drugs, vitamins, supplements, oral contraceptives, and complementary medications;
  • surgical procedures;
  • injuries;
  • hospitalizations;
  • immunizations; and
  • allergies.
• Family history: When possible, include the following information:
  
  • ages and general condition of current family members;
  • cause of death and age at time of death for deceased family members, if known;
  • specifically include any family history of diabetes, hypertension, coronary heart disease, cancer, arthritis, substance abuse (alcohol or illicit drugs), obesity, mental illness, unusual or early deaths, or known genetic illnesses, such as sickle cell disease.
• Social history: This data helps to provide a context for the patient’s life and potential risk factors. Include the following:
  
  • living arrangements or conditions;
  • lifestyle:
    
    • marital status;
    • number of children;
    • education level;
    • occupation; and
    • alternative health care practices, such as acupuncture or herbal therapies.
  • health habits or behaviors:
    
    • good or poor nutrition, exercise, sleep, or caffeine use;
    • use of tobacco, alcohol, or recreational drugs;
    • sexual behavior, especially if there are symptoms or exam findings of sexually transmitted diseases (STDs);
    • allergies to medications, foods, latex, and other environmental factors;
    • sources of stress and stress levels; and
    • domestic violence, if indicated in patient behavior or exam findings. 
• Review of systems (ROS): This section organizes a more thorough account of a patient’s condition, often organized in the patient record as going “head-to-toe.” ROS data is often collected from the patient on intake forms and reviewed together by the physician and patient during the patient visit. Negative and positive findings should be documented. Categories to include:
  
  • General or constitutional – fever, weight gain or loss, fatigue;
  • Eyes – any visual changes;
  • Ears, nose, mouth, throat – hearing loss, sinus pressure, visual changes, soreness;
  • Skin – rash, lesions, breast lump, breast discharge, hives, mole change(s);
  • Respiratory – coughing, shortness of breath, wheezing, etc.;
  • Cardiovascular – chest pain, claudication, palpitations, edema, fatigue, sweating, jaw pain;
  • Gastrointestinal – abdominal pain, constipation, diarrhea, heartburn, nausea, dysphagia, vomiting;
  • Genitourinary – dysuria, polyuria, urinary frequency, discharge, pain during or after sex, pelvic or groin pain;
  • Musculoskeletal – joint pain, back pain, knee pain, neck pain, joint swelling;
  • Neurologic – numbness, weakness, “pins and needles,” vertigo, headaches, seizures, weakness, tremors;
  • Mental health – depression, anxiety, self-harm;
  • Endocrine/metabolic – intolerance to cold or heat; polydipsia, polyphagia; and
  • Hematologic – bruising, bleeding, lymphedema, blood clots.

9. Illegible handwriting or transcribing errors, including prescriptions that may be misinterpreted by scribes or other care team members when adding information to the EHR. While electronic prescribing has become the norm, illegible and/or incomplete prescriptions or medication documentation, including missing or wrong dosage, missing or wrong frequency, and missing or wrong route of administration, can threaten patient safety. 

The use of electronic prescribing has mitigated some prescribing errors. However, if still hand-writing prescriptions, the use of decimals can cause confusion. If written too lightly or illegibly, a handwritten prescription for 1.0 mg of a medication can be misinterpreted as 10 mg. Or .5 mg can be misread as 5 mg. 

It is recommended to not use a 0 after a decimal (write “1 mg” instead of “1.0 mg”) and to use a 0 before a decimal point (write “0.5 mg” instead of “.5 mg.”)

10. Incorrect use of medical abbreviations. Abbreviations and symbols are often used to save time. However, some abbreviations may be misinterpreted if they have more than one meaning. For instance, “PID” could refer to “prolapsed intervertebral disc” or “pelvic inflammatory disease.”

According to the Patient Safety Authority, some commonly misinterpreted or misread abbreviations include:

• “U” for unit;
• “QD” for daily;
• “QID” for four times daily;
• “cc” for cubic centimeter;
• “D/C” for discontinue;
• “AU” for both ears;
• “OU” for both eyes;
• “MSO4” for morphine sulfate;
• “MgSO4” for magnesium sulfate; and
• “HCTZ” for hydrochlorothiazide. 

‍
For example, “a nurse who was taking a patient’s medication history recorded his insulin dose using the abbreviation ‘U’ instead of writing the word ‘unit.’ The physician then misread the ‘U’ as a ‘4’ and wrote for ‘Humalog 44 U/24 U/64 U.’ The patient received a single overdose of insulin but was not harmed. Further overdoses were averted because the nurse said to the patient ‘Here’s your insulin, 44 units.’ The patient responded ‘44 units? I take 4 units!’” (11)

Many organizations or hospitals maintain approved abbreviation lists to help create consistent and unambiguous records, but it is a good practice to minimize or even eliminate the use of abbreviations when documenting patient encounters. 

If using paper records, handwritten symbols can also be problematic. For example, based on an individual’s handwriting, a plus sign (+) can be misinterpreted as the number four (4), and an ampersand (&) can be mistaken for the number two (2). Take care when providing handwritten instructions or prescriptions to ensure your directions are written clearly and that they minimize or avoid the use of abbreviations or symbols. 

11. Incomplete prescription or refill information, including failing to document discontinuation of a medication. Medication errors represent the most common patient safety error, with more than 40 percent believed to be caused by inadequate medication reconciliation during patient visits or hospital stays. These errors can lead to adverse drug reactions or overdoses. (12)

‍
Do not leave data fields blank. Blank fields can be misinterpreted by others. For example, leaving a form field blank for “drug allergies” may be translated by other providers as meaning “no drug allergies,” when the person left it blank because he or she simply did not know about the patient’s drug allergies. (2)

Reviewing and reconciling patient medications at every visit is an important part of every patient encounter and should be a shared duty between a physician and the medical staff. When reviewing a patient's medication record, look for duplicates, blank fields, discontinued medications, or dose changes that need updating. 

Avoiding EHR documentation errors
Fortunately, many of these common documentation errors, such as illegibility or missing time or dates, can be avoided when using the electronic health record (EHR). But EHRs present their own documentation challenges, such as the use of “copy and paste” functions and templates. These challenges can often be mitigated by fully educating staff on EHR use and establishing clear policies and procedures for documentation.

Copying and pasting text in the EHR (also referred to as cloning, copying forward, or carrying forward), either from current or previous patient encounters, may present a significant risk to maintaining quality patient records. Copy and pasting in the EHR can result in:

• inaccurate or outdated data;
• redundancy, disorganization, data overload, and confusion;
• an inability to identify an author, accurate date, or original intent of the note; and
• continued use of false or unreliable information. 

Any one of these errors can seriously inhibit a physician’s ability to make an accurate diagnosis or make appropriate clinical decisions. 

In addition, text that is copied or carried forward from one patient encounter to the next may suggest that the treatment plan is not working or that the physician is not reviewing the record or paying close attention to the patient’s progress. While carrying over historical elements of a patient’s record may be timesaving, notes should be reviewed and edited for each patient encounter to avoid importing incorrect, redundant, and irrelevant information.

Templates are used to help physicians and staff capture required or essential patient information, such as patient history, informed consent, or other important details pertinent to their practice or specialty. However, some templates automatically fill some data fields based on past data entries or patient encounters, even though this default information does not reflect the current encounter or status of the patient. 

If this default text is not updated by the provider, “it will remain in the chart indicating that the physician completed a review of systems. If this review of systems was not done or if the findings were not normal and the [EHR] defaults to ‘normal,’ the record is inaccurate.

When investigating a medical liability claim or a board complaint, if it becomes apparent that these default statements are not true, the patient’s exam may be considered incomplete or the documentation characterized as sloppy.

Notes should be individualized for each patient encounter and relevant sections reviewed to avoid importing incorrect, redundant, and irrelevant information.” (13)

It is important when using templates or copying and pasting data to review the record at every patient encounter to make sure the information is accurate and up to date.

One benefit of using templates is that they may be customized to reflect the requirements of your specialty, office, or organization. Customized templates — edited to be clear, concise, and complete — can help reduce redundancy and errors and bring structure and clarity to patient records. 

Regularly review the templates with your team, including nurses, billing staff, and coders, to make sure the templates are optimized and accurate. If there are fields or areas that are frequently left blank or unused, consider eliminating them. Before making any permanent changes to templates, review required documentation and coding/billing elements. (14)

Establish documentation policies and procedures for EHR use in your office or practice. Your policies and procedures should define what is appropriate to capture in the EHR that increases the accuracy, breadth, and overall quality of your patient records. To avoid risk of documentation errors, policies should be written to:

• discourage or limit copying and pasting patient data as a way to improve productivity or save time; 
• encourage review of patient encounter notes before locking them; 
• outline the user's responsibilities when it comes to copied information and notification of errors; and
• detail disciplinary actions for unethical or inappropriate documentation practices. (15)

Additional risk management considerations when using an EHR include: (14)  

• Ensure patient encounter records are “locked” once complete. Information found in an EHR is likely to be more accurate if entered during or immediately after a patient visit. Once a patient encounter entry is completed, the author should sign it, date it, and lock it in the system. Note that not all EMRs are set to perform this task automatically; make sure you know how to finalize your notes in the EHR system.

• Clearly identify addendums. If information needs to be added or comments made after an entry is locked, clearly identify the new entry as an addendum with the current date, reference to the original entry date, the reason for the late entry (if significant changes are made), and electronic signature. Unclear, after-the-fact entries may be viewed as alterations to the medical record, which can create legal complications.
  
• Make sure physician sign off is clear. A physician may believe he or she has “signed off” on a note when closing it, but this may not be case. Review your EHR functionality to confirm that you are appropriately signing, dating, and “locking” all notes. Ensure that all physicians or any staff member making entries know how to properly sign and finalize entries in the EHR system.

• Review orders or emails before signing off with electronic signatures. Signing an order confirms that it is correct. “Avoid auto-authentication techniques that do not require the author to review the entry. Do not ‘universally’ approve or sign off on a series of orders, emails, or internal messages without reading them.” (14)

• Enable tracking mechanisms. Most EHR systems include an electronic order tracking system to help ensure that patients have completed recommended tests or consultant referrals. These tracking systems can provide ways to:
  
  • verify that a patient keeps an appointment or completes a test;
  • confirm receipt of a report;
  • prompt a call to the consultant, imaging center, or lab if a report is not received;
  • make sure the physician reviews the report;
  • facilitate documentation of review, sign off, and any actions needed in response to test results;
  • prompt communication of results to the patient;
  • assist in scheduling a follow up appointment if necessary; and
  • document all these steps with dates and electronic signatures.

• Establish a system to appropriately capture paper and other external clinical documents. Optimally, all paper documents should be scanned into the electronic record for easy access. These documents could include paper records used before implementing an EHR, paper forms completed by the patient, diagnostic test results, consultant reports, hospital reports, or records from other physician offices. Additionally, a process should be implemented to ensure that, once scanned, the paper documents are properly stored or destroyed.

While scanning a patient's entire paper record into the system is preferred, it is not always possible. Some patients' previous medical records can be hundreds of pages. In these cases, physicians can review the records, summarize them, and include that information in the patient's history within the EHR. Whatever process you adopt, it is important to develop and maintain a policy for capturing patients' previous medical records.

• Ensure paper prescriptions are reflected accurately in the record. If using paper prescriptions, they should be captured by scanning the paper prescription into the EHR or fully documenting the name, dose, quantity, frequency, instructions, and refill amount. Potential side effects or risks should also be documented. The same is true when dispensing sample medications to a patient. (14)

Working with a scribe

One way hospitals, practices, and organizations have found to ease the administrative and time demands put on physicians due to documentation is by using medical scribes. A medical scribe is typically an advanced practice provider, nurse, or other staff member who works with a physician to document all pertinent patient encounter information, often in real time. 

A 2021 study found that the use of medical scribes has been mostly beneficial to creating patient records and helping physicians to shift their attention away from the EHR and more toward personal interaction with their patients. (16) 

The same study offered that many physicians feel that scribes provide an “extra layer” of legal protection for them. Having a “witness” in the room helps both the physician and the patient verify the information shared during the encounter. Other physicians, particularly those in high stress environments like the emergency department, felt that the mere presence of “a third person in the room makes patients behave better.” (16)

Another benefit of employing scribes is that these individuals usually become extremely adept at using the EHR and become “EHR experts,” offering help to others in an organization or practice. 

This same study recommended the following best practices for working with scribes.  

• Records must clearly describe the actions or service of the provider during each individual patient encounter, who documented the service, and the qualifications of each person, such as professional degree or medical title.
• Ensure that the scribe’s role and responsibilities are clearly assigned to avoid “scope creep.” There have been instances in small clinics and rural areas where a scribe’s role has gone beyond documentation to a broader set of duties that the scribe was not licensed to perform. Scribes must keep their roles clearly separate from those offering clinical care. 
• All notes should be signed and dated by both the provider and the scribe. 
• Documentation completed by scribes must be constantly reviewed to ensure accuracy, completeness, and overall quality. This responsibility is especially necessary while training a new scribe. It can generally take a scribe six months to become well oriented to the health care environment, the behaviors and reasoning of the physician he or she works for, clinical terminology, and how the EHR system works. During this time, the physician will need to spend extra time reviewing the scribe’s work and documentation. 
• It is important that there is good communication between the physician and the scribe and that both feel comfortable giving and receiving criticism or feedback. To produce positive interactions, efforts should be made to find a scribe that will be a good personality “fit” for the physician. This may not always be apparent during hiring but may be helped by establishing that the relationship will resemble one between a mentor and a mentee. This will help foster a mutually beneficial relationship for both the physician and the scribe. (16)

SIDEBAR: Documentation in your medical practice

Upon request, TMLT Risk Managers visit physician practices to help improve patient safety and increase defensibility in the event of a claim, lawsuit, or medical board complaint. Among the most common risk management recommendations given to physicians in 2023 were these five documentation issues — some of which are previously discussed in this article.

• Visit notes lacked documentation regarding who accompanied the patient to their visit. This may be critical information if the patient is a minor child, an impaired adult, or an elder adult that needs additional assistance.
• Review and update of current medications was not done or was not documented in the record. Risk managers often saw medications that should have been discontinued remaining for months or years on “current medication” lists. In some records, it was unclear that the medication list had been reviewed with the patient and updated appropriately.
• Medical history was not updated. New patient conditions, surgeries, or other pertinent information were not added to the record. Or past acute conditions appeared in the “current problems,” when they should have been noted as “resolved.” This could make it appear erroneously that a serious concern was either ignored or not improved.
• Allergy information was not updated or documented consistently, or NKDA (no known drug allergies) was not noted in the record. Leaving the allergy section of records blank is never recommended; it should always be noted if a patient reports no allergies. Allergies should be addressed with the patient at each visit and the record updated accordingly.
• Patient education — via handouts, discussion, or other instructions — was not consistently noted in the record. Physicians engage in hours of education of their patients. With the advent of new laws that allow patient access to their own records, documentation of this education is especially important. If documented in the EHR, patients can quickly access and review instructions, precautions, and other information that was given to them during or after their visit.

Conclusion

The benefits of creating and maintaining quality patient records are many. A thoroughly documented record provides the physician and care team with a full picture of a patient’s condition and greater insight into a patient’s risk factors. This ensures that all providers have the necessary information to evaluate the patient and make quality treatment decisions. On the other hand, a poorly documented or maintained patient record can lead to higher incidence of error and potential legal action.

Clear, complete, and logical documentation offers recorded, authenticated proof that the individual physician provides excellent, timely, and meticulous care. It further demonstrates how the physician puts patients first, through considerate, thoughtful, and caring treatment. 

Sources

1. Freedman, M. Patient Demographics and Why They’re Important. Business News Daily. February 8, 2024. Available at https://www.businessnewsdaily.com/16329-what-are-patient-demographics.html. Accessed February 13, 2024.
2. MOS Medical Record Reviews. Poor quality medical records – Reasons and solutions to address them. Updated September 9, 2023. Available at https://www.mosmedicalrecordreview.com/blog/poor-quality-medical-records-reasons-and-solutions-to-address-them/. Accessed February 13, 2024.
3. Texas Administrative Code. Chapter 165.1. Medical Records. Amended to be effective November 10. 2019. Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed February 13, 2024. 
4. Texas Medical Liability Trust. Medical record regulations in Texas. Resource Hub. Available at https://hub.tmlt.org/tmlt-blog/texas-specific-medical-record-regulations. Accessed February 13, 2024.
5. Nijor S, Rallis G, Lad N, Gokcen E. Patient Safety Issues From Information Overload in Electronic Medical Records. Journal of Patient Safety. April 2022. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9422765/. Accessed February 14, 2024.
6. Lack of informed consent. Standards of Care website. Available at https://www.standardsofcare.org/medical-malpractice/types/lack-informed-consent/#:~:text=Failure%20to%20get%20informed%20consent%20can%20be%20considered%20negligence%20if,decision%20if%20given%20better%20information. Accessed February 14, 2024.
7. Illinois Chiropractic Society. Documentation errors that can place you and your practice at risk in a malpractice lawsuit. Available at https://ilchiro.org/documentation-errors-that-can-place-you-and-your-practice-at-risk-in-a-malpractice-lawsuit/. Accessed February 14, 2024.
8. Texas Medical Liability Trust. Informed refusal: When patients decline treatment. TMLT Resource Hub. Revised March 2023. Available at https://hub.tmlt.org/tmlt-blog/informed-refusal-when-patients-decline-treatment. Accessed February 14, 2024. 
9. Brockway L. Informed refusal: When patients decline treatment. Revised March 30, 2023. Texas Medical Liability Trust Resource Hub. Available at https://hub.tmlt.org/home/informed-refusal-when-patients-decline-treatment. Accessed February 16, 2024.
10. Park J, Saha S, Chee B, et. al. Physician Use of Stigmatizing Language in Patient Medical Records. JAMA Network Open. July 14, 2021. Available at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781937. Accessed February 21, 2024.
11. Patient Safety Authority. Abbreviations: A Shortcut to Medication Errors. March 2005. Available at https://patientsafety.pa.gov/ADVISORIES/Pages/200503_19.aspx. Accessed February 14, 2024. 
12. Barnsteiner JH. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 38 Medication Reconciliation. 2008. Available at https://www.ncbi.nlm.nih.gov/books/NBK2648/. Accessed February 15, 2024. 
13. Texas Medical Liability Trust. Medical record regulations in Texas. TMLT Resource Hub. Available at https://hub.tmlt.org/tmlt-blog/texas-specific-medical-record-regulations. Accessed February 21, 2024.
14. Zaner K, Brockway L. CME: Electronic medical records: A practical guide. Reporter Q2 2022. Texas Medical Liability Trust. Available at https://hub.tmlt.org/reporter/reporter-q2-2022. Accessed February 21, 2024.
15. Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in Health Information Management. October 2013. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797550/#app1. Accessed February 20, 2024.
16. Ash JS, Corby S, Mohan V, Solberg N, et. al. Safe use of the EHR by medical scribes: A qualitative study. Journal of the American Medical Informatics Association. February 2021. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883983/. Accessed February 21, 2024. 

Wayne Wenske can be reached at wayne-wenske@tmlt.org.