Accurate Medical Records: Your Primary Line of Defense

By Mark Gorney, MD, FACS (deceased), Governor Emeritus, Richard Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Director, Patient Safety Education.

Every medical malpractice suit can be won or lost based on the quality and content of the medical records.

A suit without merit can be lost because the medical record was vague, incomplete, or altered. Conversely, a potentially damaging suit can be won because the medical record was precise, thorough, and accurate—and events were well documented.

The Doctors Company is adamant about the critical need for every physician to maintain meticulous records. If you are faced with a malpractice claim, your record keeping will help us provide the best possible defense.

General Guidelines

Observe these general guidelines when completing a medical record.

Hard copy (paper) records:

  • Ensure medical record entries are clear and readable. If possible, dictate all long entries that require more than brief or routine annotations.
  • Never squeeze words onto a line or leave blank spaces. Draw diagonal lines through all blank spaces after an entry.
  • Never erase, write over, ink out, or use whiteout on an entry. In case of error, draw a single line through the incorrect entry, and write the date, the time, and your initials in the margin.
  • Never add anything unless you write a separately dated and signed note. The patient, a third-party payer, or a plaintiff’s attorney may have obtained a copy of the original records.
  • Always indicate the date and time of an entry. Ensure each page includes the patient’s name and that each progress note is accompanied by the date and time. Make certain all entries are initialed or signed.
  • Always keep a record of when and by whom a patient’s medical record is photocopied.

Electronic medical records:

  • Remember that anything typed is permanent and discoverable in a metadata audit.
  • Avoid the dangerous practices of copying or cutting and pasting.
  • Never give your personal identification number or login information to anyone.

For all medical records:

  • Include a detailed and accurate medical history, physical findings, differential diagnoses, treatment plan, care rendered, advice given, and all other matters pertinent to the patient’s medical course.
  • Avoid personal abbreviations, ditto marks, or initials. Use only standard and accepted medical abbreviations.
  • Do not use lengthy, self-serving entries that may appear defensive in nature when explaining a complication or medical catastrophe.
  • Do not use the patient’s record as a place to record confidential communications between you and your professional liability insurance carrier or your attorney—or to criticize another caregiver.

Use Specific Language

Avoid imprecise language, generalizations, and statements that are subjective rather than objective.

Examples include the following: 

  • Imprecise: Doing OK.
    Accurate: Less pain today. Ate full diet.
  • Subjective: Appears depressed.
    Objective: Crying and worried about progress.
  • General: Wound OK.
    Specific: Surgical incision healing. No sign of infection.

Rely on your senses to describe your observations: 

  • See: Color, abnormality, posture.
  • Smell: Breath, drainage, excretions.
  • Hear: Sounds of breathing, crepitation, bowel sounds.
  • Feel: Hot or cool, dry or moist, soft or firm.

Document patients’ verbatim statements: 

  • Incorrect: Patient apparently fell.
    Correct: Patient states “I tried to get up, tripped, and hit my head on the corner of the bed.”

Detailed documentation is most important when: 

  • You are going to be absent from your practice. Include the name of the covering physician and the date and time you signed out. Provide the covering physician with pertinent observations and follow-up information for any abnormal situation.
  • Justifying your failure to comply with—or your rejection of—a consultant’s advice.
  • Outlining your viewpoints and reasons for any disagreement on patient care between you and a hospital utilization review committee, a preferred provider organization, or a managed care receiver.
  • Explaining delayed responses to a nurse or house staff calls, including dates and times.
  • Recording your responses to nurses’ pertinent observations of a patient. (Be sure to record the follow-up information in your progress notes.)
  • A patient experiences a negative reaction to any treatment or medication.

A Checklist Helps to Protect You

Using a list of the following entries can remind you of what should appear in the office or hospital records of each patient:

  • Results of a patient’s physical examination, specifically noting the absence of abnormality.
  • Patient history and a list of all medications with particular emphasis on current medications. Include over-the-counter drugs and supplements and any allergies or drug sensitivities.
  • Specific notation on the patient’s experience, if any, with drug or alcohol abuse and family or emotional problems.
  • Progress notes, entered after each office visit, about any change in status. (If negative, your follow-up should be indicated.)
  • Signed and witnessed consent forms for special procedures or surgery.
  • Patient response to medication or procedures.
  • Patient failure to follow advice or to keep appointments and any refusal to cooperate. (Log missed appointments and follow-up telephone calls and letters.)
  • All significant laboratory or x-ray reports and the dates that they were ordered and read.
  • Copies or records of instructions of any kind (including diet) and directions given to the family.
  • Records of consultations with other physicians and their written or oral responses, with the dates and times.
  • Thorough documentation of any patient’s grievance, including the date and time.

Patient Care Instructions

  • Always record your instructions in writing.
  • Review your instructions with the patient and the patient’s family.
  • Ensure comprehension. Use a teach-back method to confirm that the patient can accurately describe his or her treatment plan. Record the patient’s response.
  • Document language limitations and attempts made to overcome them through the use of translators, as well as any questionable comprehension. Note any literature provided to the patient and family.
  • Retain a copy of any instructions given to the patient and family.
  • Note patient failure to comply with instructions and your efforts to inform the patient of the risks of nonadherence.

Instructions and Information to Include (When Applicable)

  • Specific wound care.
  • The amount of incisional bleeding to be expected.
  • Limitations of activity, position, or exercise.
  • Dietary restrictions.
  • Specific instructions for medications, including possible side effects and when the patient can resume preoperative medications.
  • Anticipated postoperative pain and time frames for analgesia.

Conclusion

In the event of a claim, your medical records are a vital part of your defense. Using these guidelines to ensure precise, thorough, and accurate records is crucial to your protection and defense.


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10097 4/15

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