An old Chinese proverb says that “the faintest ink is more powerful than the strongest memory.” This adage is apropos when considering the importance of medical record documentation.
Today, the majority of documentation is accomplished via electronic health records (EHRs). This enhances record keeping but also presents certain pitfalls. As an illustration: Although EHRs provide a ready use of templated language to facilitate documentation, the templates increase the danger of not differentiating between each patient.
By thorough analyses of closed claims, The Doctors Company can readily identify claims in which documentation—whether accurate, faulty, delayed, or missing—contributed to the success or failure of defending a doctor’s care. Documentation is a factor that contributed to patient harm in 19 percent of all claims and suits filed from 2010 through 2019. Key deficiencies included a lack of documentation of clinical findings, clinical rationale, and informed consent. The quality of documentation also affects the way a jury perceives the defendant doctor and, if flawed, may undermine credibility.
Ensure Quality Documentation
Assess the quality of documentation in your practice with routine audits of medical records. Audits are often done for coding purposes, but there should also be a review of the quality and completeness of documentation that focuses on continuity of care and communication with the care team. A review using standardized criteria should occur at least quarterly.
Common areas of weakness in documentation that make it difficult to defend the care provided include the following:
- Use of nonstandard or personal abbreviations.
- Lack of documentation of the physician’s response to diagnostic study results and no information on how the results were communicated to the patient.
- Sparse or missing documentation of phone calls involving patients. Documentation for each phone message should include the date and time of the call, who received it, the nature of the conversation, how the call was managed, to whom the message was referred, and the follow-up plan.
- Missing documentation of after-hours calls.
- Sparse or missing notes on a patient’s response to treatment.
- Absence of documentation on informed consent discussions, including the patient’s specific questions and whether anyone else was present during the discussion.
- Missing documentation on when the patient should return or other follow-up plans.
- Unclear documentation of an addendum or amendment to the medical record.
- An addendum is intended to record information not available when the original entry was made. It should include the date of the addendum and an explanation about why the entry is needed.
- An amendment is used to correct an erroneous entry and may also be requested by a patient. It should include the date of the amendment and a brief explanation about why the patient requested it.
- Lack of a documented rationale when not following the recommendations of consultants.
- Missing or incomplete documentation of patient noncompliance with the treatment regimen and practice efforts to improve compliance.
- Missing information about patient complaints or grievances. It may be desirable to include a direct quote of any comments.
- Self-serving comments and additions to the record made after a potential claim has been brought forth.
Pitfalls of Copying and Pasting
Many EHR systems have a copy-and-paste feature. If you use this feature, carefully review the text you copy to ensure that it accurately describes your patient’s current condition. In some cases, the defense of a lawsuit was compromised by the physician’s use of the EHR copy-and-paste function because the entries had no personalization and were all nearly identical. Another pitfall is copying and pasting a portion of documentation that is no longer relevant to the patient. It can give the impression that the physician is lazy or careless.
Medication documentation should include a current list of all medications the patient is taking—both prescription and over the counter. During each visit, confirm the medication list and update it as appropriate. When new medications are prescribed, the next visit should include a comment on the effect of the medication and how it was tolerated by the patient.
E-prescribing can result in serious errors if the prescription is not carefully reviewed before being sent. While you may have a staff member enter the information, you assume all responsibility for accuracy once you sign the prescription. A well-designed EHR will list medication choices on the drop-down menu according to the strength of the drug in ascending order (lowest dose as first choice). This prevents selecting the strongest dosage in error. If your system lists medication doses in descending order (strongest dose at the top of the drop-down menu), consider making a system adjustment.
Documentation by Others
If you utilize other clinical staff to enter some of the history and physical information, be certain the identity of that person does not disappear when you are entering your portion. (Some systems have that flaw.) The identity of every person making entries in the record should be clear.
If you utilize scribes for assisting in documentation, it is important to hire staff with the required skill set and carefully review their work. Ultimately, you are responsible for the content of the documentation.
If a patient refuses a recommended treatment or therapy, include documentation of the refusal in the record and outline your discussion of the risks and consequences of the refusal. Documentation of an informed refusal is as important as documentation of informed consent.
If educational materials are given to patients, the record should reflect exactly what the patient received. Additionally, if you provide printed discharge instructions, they should be a part of the record. This information is especially important for continuity of care within your practice and for any subsequent treating physician.
Timeliness of entries in your medical record is critical. The more time that elapses between the patient encounter and note entry, the more likely it is that the record will be missing complete and accurate details. Memories can be affected when similar patients are cared for within the same time frame. Late entries can also be used as evidence against you in a trial. EHRs contain metadata showing exactly when data is entered in the record and who made the entry. It is now becoming commonplace for plaintiffs’ attorneys to access that data.
Regardless of the medical record’s format, it tells the patient’s story and provides information that is necessary for ongoing patient care and care coordination. Cases have been won or lost on the strength or weakness of the documentation. A well-documented medical record is essential to providing quality care, and it supports the physician if litigation occurs.