Document the medical record appropriately—for your own and your patient’s benefit

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 medical care.

Liability experts estimate that 35 percent to 40 percent of suits alleging malpractice are indefensible because of problems with medical records. Weak, flawed, or absent documentation has a powerful impact in eroding your credibility.

Detrimental documentation practices include gaps or delays in documentation, illegible entries, transcriptions with blank spaces, unflattering patient descriptions that appear judgmental, entries that appear to vent negative feelings, altered records, and records missing documents or entries.

Physician groups should routinely assess the quality of their documentation. 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, the group may want to define acceptable time frames and protocols for completing records, correcting entries, authenticating entries or reports, and documenting late entries.

Dictation
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 affect the timing of further testing or therapy for the patient.

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.

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, so 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 an unnecessary entry. All transcription should document the dates it was dictated and transcribed.

Increasingly, physicians are choosing to dictate in the presence of the patient to create a contemporaneous record of the encounter, either 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 uses electronic signatures, be certain that it conforms to state or federal requirements.

Even the best systems can lose dictation, and this may not be discovered until 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, then dictate a report containing what you can remember. Indicate that the brevity of the report is due to loss of the prior dictation. Acknowledging the appropriate timeline when the dictation was lost and when the second dictation occurred is important.

From a risk perspective, including “dictated but not read” statements is unacceptable. 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
Correcting erroneous information in a medical record document 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, 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 you must 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 being strictly self-serving or if it is being written long 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.

A well-documented medical record is essential to providing quality care, and it supports the physician if litigation occurs. It enables the practitioner to make timely decisions predicated on all the information about the patient that can be assembled. It helps ensure that current members of the care team have the critical information needed to coordinate care efforts, and it provides subsequent caregivers with crucial information to support the continuity of care.

Carol Murray, RHIA, CPHRM, is a patient safety/risk management account executive with the Central Regional Office of The Doctors Company. This article is reprinted with permission of The Doctors Company.

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor Douglas W. Lundy, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

Problem areas
Chart audits have identified the following problem areas in documentation:

• 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 (creates opportunities for conflicting information)
• Missing documentation of physician review of results of diagnostic studies
• Missing 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