Medical Record Documentation: Do’s and Don’ts

Medical Record Documentation: Do’s and Don’ts

Contributed by Peter Spataro and Morgan Murphy, Brown & James, P.C.

If your patient suffers complications and decides to file a lawsuit against you, your medical records will come under intense scrutiny. The saying goes, “hope for the best; prepare for the worst.” A thorough medical record is the best way to prepare for “the worst,” and as a practicing physician, “the worst” usually involves a lawsuit. We medical malpractice attorneys frequently see inadequate or problematic documentation which complicates, or even occasionally causes, a lawsuit.

Below are some brief “Do’s” and “Don’ts” for patient documentation in your office.

DON’T: Overuse automatic or pre-filled entries, which leads to inaccuracies. One of our doctors noted that a patient with severe lumbar pain and a history of spinal fusion had a “normal” spinal range of motion. Another noted his patient had a normal, non-distended abdomen during a visit for a skin lesion, yet a month later the patient was found to have an enormous abdominal tumor. Such obvious discrepancies make a medical record look sloppy.

DO: Be thoughtful about using pre-filled entries or drop-down menus, and change the default entries if the patient’s condition is not consistent with the default.

DON’T: Blindly copy and paste standard entries or entries from the patient’s prior office visit. Repeating the history and physical from the prior visit may be easier than starting anew, but your entries must be reviewed to change the history and physical where necessary. Even worse, repeat copying and pasting may cause the perpetuation of original inaccuracies.

DO: Thoroughly document your exam. A “normal” exam may not seem worth documenting, but if you get sued for a failure to diagnose, you will wish you had documented every normal finding in detail. Consider a case where our doctor saw a patient just twenty-four hours before she became quadriplegic. He documented a “normal” neurologic exam, but in retrospect his defense would have been much easier if he had documented 5/5 strength in the extremities, sensitivity to pinprick, and other concrete details.

DON’T: Rely on staff members to assess a sick patient over the phone unless that person is a trained health care provider and thoroughly documents the phone conversation. You may not be able to see a patient immediately, but your decision not to see a patient will be questioned should complications result.

DO: Document any treatment-related phone calls very thoroughly. If the patient will not come into the office, either document that the patient does not want to be seen in the office, or take a thorough history over the phone and preserve documentation of the history in the patient’s chart.

DON’T: Write anything in an email, text message, or other electronic message that you would not be comfortable including in the medical record. As technology advances and health care providers increasingly communicate more informally, plaintiff’s malpractice attorneys are requesting emails and electronic communications that do not form part of the patient’s traditional medical record. We cannot guarantee that such interpersonal messages will be protected from discovery, so treat such patient-related communications with the same dignity you would treat an entry in the patient’s chart.

DO: Document all significant communication regarding a patient, including orders, in his or her medical record. One of our clients left a note for one of his nurses to order some additional tests following an abnormal lab result at the nurse’s desk. The order was never entered. In another case, our staff ordered a lab which showed that the patient never had an infection, yet no one ever followed up to obtain the test results from the laboratory. These snafus may have been avoided had the medical record more clearly documented that such orders were in place and needed follow up.

DON’T: Change the content of a medical record after the fact in a way that is inconsistent with the original content. HIPAA requires that electronic medical record systems today have an “audit trail,” a mechanism of documenting all changes to a medical record, including identifying when a document is changed, by whom, and what changes were made. A plaintiff’s attorney loves nothing more than seeing that a medical record was substantively changed after the fact, especially when such changes occur after the patient experiences a complication. Consider that all changes to the electronic medical record can be tracked.

Finally, remember that if you are in doubt about how to handle your medical record or how to proceed when you have a patient known to be unsatisfied with your medical care, contact Keystone Mutual for assistance.