Since 2018, nearly 49% of our closed claims?with risk issues have involved issues relating to documentation or electronic medical records. This statistic highlights the importance of timely and comprehensive documentation in health care settings. Accurate documentation clarifies misunderstandings, supports continuity of care, and, in the unfortunate event of medical liability litigation, can serve as evidence of your rational medical decision making.
Health care providers should consider the following simple risk mitigation strategies related to documentation:
1. Document your patient encounter while it is fresh in your mind.
2. Document all issues discussed with your patient during the patient encounter.
3. Document all calls, messages, and conversations with your patient that occur outside the patient encounter.
4. Document consultations with other members of your patient’s care team.
5. Document the differential diagnoses for your patient.
6. Document a plan of care for your patient by outlining your intended treatment strategy, goals of treatment, expected outcomes, and any reasons for not following alternative treatment strategies.
Consider the impact of weak documentation in the following hypothetical scenario: Suppose you are a primary care provider of a patient you have treated for several years. When the patient sees you for their annual wellness exam at age 50, you recommend a screening colonoscopy. For a variety of reasons, the patient chooses to defer the colonoscopy and does the same the following year. Your routine is to make the recommendation and you have an independent recollection of the making one for this patient, but you did not explicitly document your recommendation in the patient’s chart. Instead, the chart contains a simple one-line statement that you selected from a dropdown menu in your EMR system: “Discussed preventive care.” Sadly, at age 52, your patient is diagnosed with metastatic colon cancer. When you learn about the patient’s diagnosis, you make a note in your EMR that references your prior recommendation. Unfortunately, the patient has now filed a lawsuit against you claiming that you failed to make the proper recommendation and, therefore, caused a detrimental delay in their cancer diagnosis.
Without a contemporaneous record of your recommendation, your defense relies almost entirely on your credibility as a witness. Your cross examination at trial will be challenging. So, remember: timely and comprehensive documentation is essential to a strong defense of good medical practice.
