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.
Liability experts estimate that 35 to 40 percent of suits alleging malpractice are indefensible because of problems with medical records. Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen your credibility if you are called upon to defend that care.
Weak, flawed, or absent documentation has a powerful impact in eroding your credibility. 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 very complex malpractice case. Poor documentation practices can also have a deleterious impact on the various individuals surveying 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 their documentation routinely. A group could compromise the outcome of a malpractice claim if it fails to identify and act when one of its members consistently produces inferior documentation, deficient in timeliness and critical content.
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.
Dictation
Good practices also apply to dictated reports or visit notes. Dictation must be timely—no longer than 24 hours after the encounter. If the report or note is dictated later, include an explanation for the delay. This is critical to a defensible record because the delay could impact the timing of further testing or therapy for the patient. For example, a delay in a history and physical might deprive members of the care team of critical information about allergies, medications, chronic conditions, or suspected disease processes. A delay could be used by the plaintiff’s counsel to demonstrate substandard care or to suggest alteration of a record.
The Joint Commission has specific guidelines for postoperative notes. When the dictated note is not immediately available to staff, the physician must provide a handwritten note prior to the patient’s transfer to the next level of care.1
The content of dictated office records should include diagnostic and therapeutic plans and rationale, response to therapy, modifications to or deviations from the original plan of care, and an adequate explanation of the complexity of the patient’s condition or therapy. If you are consulting with another provider, include an endorsement of or comment on why you are not following the consultant’s recommendations. If shared management of a patient is in place, indicate which aspects of care will be handled by each provider.
Transcription should also occur on a timely basis and, if it is delayed, include an explanation on the chart copy. Transcription should always be reviewed and authenticated by the author. Any blanks in the transcription should be addressed by either entering the correct information (with initials) or lining through the entry if it is not needed. All transcription should document the dates it was dictated and transcribed.
To increase accuracy in transcription, speak slowly and have any reports or other chart information that you plan to reference in the dictation at hand. Spell any new terms, infrequently used terms, and the names of medications. Be very careful when dictating lab values to prevent transcription errors.
Increasingly, 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 medical record (EMR), which the physician or scribe uses when entering information into a template.
Improved technology can also enhance the dictation process. Handheld equipment, template-driven systems, and voice-recognition software can all be assets.
Physicians who are involved in dictating reports that interpret medical information are also responsible for reviewing and signing the reports. Avoid having physicians sign for each other. If your system utilizes electronic signatures, be certain that it conforms to state or federal requirements.
Even the best systems can lose dictation. Ironically, this is sometimes discovered when a malpractice suit is filed. In this situation, the best practice is to document the date and time that you became aware of the missing document, and 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 only calls attention to questions about the quality of care.
Outsourcing transcription can create additional risks, such as privacy violations. When selecting vendors, be sure to evaluate the level of staff training on privacy and HIPAA regulations and on medical terminology (including additional terms related to your specialty). Set acceptable turnaround times and the process for making corrections. Vendors should provide access to reports prior to transcription and have a solid system for preventing lost dictation and transcribed reports.
Correcting an Entry
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. Note that it is a corrected entry, and initial and date it. If it is not apparent that it is a corrected entry (if, for example, the correction had to be placed later in the record), be certain to include an explanatory comment.
If it is necessary to make a late entry or addendum, insert it after the last documentation. Do not try to insert the note or squeeze it into a prior entry. Don’t obliterate earlier entries. Include a comment that the note is an addendum to prior information in the record. If the entry could be construed as strictly self-serving or if it is being written a long time after the care was provided, it is best to not include it in the medical record.
Forms and Templates
Documentation can be enhanced by effective use of forms or templates. In the electronic record environment, documentation can be accomplished by integrating forms and templates into the actual 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.
Forms are an excellent way to provide easy access to important information. We encourage physicians who provide ongoing care to consider using forms for current problem lists and medication profiles. To ensure that forms are used effectively, require all providers in the practice to use them consistently.
Formatted progress notes can be helpful for consistent documentation and can help the practitioner who has problems with legibility.
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 about the patient that can be assembled. It helps to ensure that current 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.
Problem Areas
Here are some of the problem areas identified through chart audits:
- Missing dates and signatures
- Using unclear or nonstandard abbreviations
- Correcting erroneous entries incorrectly (with complete obliteration of the entry)
- Logging allergy information in multiple areas of the chart—which creates opportunities for conflicting information
- Lacking documentation of physician review of results of diagnostic studies
- Lacking documentation that patients are informed about the results of diagnostic studies
- Including late entries in the patient’s chart
- Missing or inadequate documentation of follow-up plans
- Missing or limited documentation of phone calls with patients
- Missing documentation of a patient’s response to therapy or of noncompliant behaviors
In today’s patient safety–focused environment, other 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 by including a complete discharge summary. A complete summary includes obvious 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.