An old Chinese proverb says that “the faintest ink is more powerful than the strongest memory.”
This adage has great applicability when discussing the best ways to document your medical care.
The Doctors Company closed claims studies frequently cite inadequate or lack of documentation as a risk factor. Weak, flawed, or absent documentation can have a powerful impact if you are called upon to defend patient care. More often than not, a jury will consist entirely of people with no medical background. The medical record can reinforce or destroy your credibility, and it can be a significant factor in determining the outcome of a complex malpractice case. Poor documentation practices can also have a deleterious effect on any individuals or entities that survey your records—ranging from insurance companies to accrediting bodies or state medical boards.
Detrimental documentation practices include gaps or delays in documentation, illegible entries, dictation with blanks, unflattering patient descriptions that appear judgmental, entries that appear to vent negative feelings, altered records, and records missing documents or entries.
We encourage physician groups to assess the quality of documentation routinely. Set up a system for monitoring medical records that is based on specific policies and procedures. For example, you may want to define acceptable time frames and protocols for completing records, correcting entries, authenticating entries or reports, and documenting late entries.
Many physicians are choosing to dictate in the presence of the patient to create a contemporaneous record of the encounter. This can be accomplished by actual dictation or, in some offices, with an electronic health record (EHR), which the physician or scribe uses when entering information into a template.
Physicians who are involved in dictating reports that interpret medical information are also responsible for reviewing and signing those reports. Avoid having physicians sign for each other. If your system uses electronic signatures, be certain that it conforms to state and/or federal requirements.
Even the best systems can lose dictation. Ironically, the loss is sometimes discovered when a malpractice suit is filed. In these types of situations, the best practice is to document the date and time that you became aware of the missing document, then dictate a report containing what you can remember, and indicate that its brevity is due to prior dictation being lost. It is important to acknowledge in the appropriate timeline when the dictation was lost and when the second dictation occurred.
From a risk perspective, it is not acceptable to include “dictated but not read” statements in dictation. It does not relieve the author of responsibility for the accuracy of the transcription, and it only calls attention to questions about the quality of care.
It is often necessary to correct erroneous information in a medical record document. Corrections should never be made after a claim or suit has been brought forward. If you need to correct a record in the normal course of care, it is appropriate to mark the original entry with a notation of error without obliterating the erroneous information. It is important to be familiar with the proper method of making corrections as required by the specific EHR software in use.
Documentation can be enhanced by using forms or templates effectively. In the electronic record environment, documentation can be accomplished by integrating forms and templates into the software.
Patient health histories capture important information to assist in documenting a thorough history and physical examination. The forms should be signed by the patient and, when complete, initialed by the physician after review.
Here are some of the problem areas identified through chart audits:
Benefits of thorough documentation include a decrease in errors related to miscommunication and an enhanced continuity of care.
One of the best ways to strengthen the continuity of care for patients who are discharged from the inpatient setting is to include a complete discharge summary. A complete summary contains basic elements, such as diagnosis, pertinent physical findings, and the results of diagnostic studies (lab tests, for example). Additionally, it is helpful to include details of medications prescribed at discharge with the rationale, frequency, dosage, and the proposed length of the treatment regimen. You might also include post-discharge plans specifically relating to any consultants, planned testing, outstanding reports needing follow-up, and the discharge instructions given to the patient.
A well-documented medical record is essential to providing quality care, and it supports the physician if litigation occurs. This can only happen with a personal commitment to the importance of clinical documentation.
An informative medical record helps the practitioner make timely decisions predicated on all the information that can be assembled about the patient. It helps to ensure that members of the care team have the critical information they need to coordinate care efforts, and it provides subsequent caregivers with crucial information to support the continuity of care.
By Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.
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.