“If it’s not documented in the medical record then it didn’t happen.” How many times have plaintiff’s counsel used this in the court room?  It’s an age old saying, but the reality is much happens that doesn’t get documented. The real issue: is the documentation in the medical record complete, accurate, and concise (and yes, timed/dated). 

Risk Management does not advocate to write more, but rather to record the facts and findings regarding patient care so that the record reads like a book. The patient’s chart is about continuum of care. If a record is well documented to facilitate care then there is no worry that the record will be a liability if there ever should be a claim. Defensive documentation should not drive how a chart is generated.  

While the medical record is not what brings on the initiation of a given law suit, the record itself can be what increases the value of the lawsuit or enables a lawsuit to move forward. Sloppy documentation is equated with sloppy care.  Sloppy documentation can result in sloppy continuum of care. The record is a legal document so understand that what you write is memorialized permanently. What you don’t write is questioned forever. What you write can change the course of care and/or can change the course of your physician/patient relationship. The medical record belongs to the patient. (While original is maintained in hospital/your practice, the information belongs to the patient. He/she is entitled to the information and/or copy).

The answer is NOT to avoid or shy away from documenting in the medical record. Documenting is a critical component to the delivery of healthcare. It is a tool to:  

• Ensure continuity of care as it serves as a communication tool among healthcare providers
• Plan and evaluate a patient’s treatment
• Create a permanent record for the patient’s future care
• Create a database to evaluate effectiveness of treatment
• Facilitate research
• Substantiate billing
• Recollect a memory and/or justify/defend care provided.

Document intelligently and clearly. Below are a few tips to help protect against an allegation of falsifying a medical record: 

• Date, time, and sign every entry
• Make entries immediately or soon after care is given
• Write legibly
• Be thorough, accurate, and objective
• Only used approved abbreviations

There are times when an addendum to the chart is necessary. Note, it is acceptable to make an addendum, but before documenting ask yourself if it is a note to enhance the record and provide continuum of care or is it a “cover yourself” note. A progress note written two years post care, on the day you receive a notice from an attorney, is not the appropriate time to be making an entry. 

Documentation is a form of communication… it should be done timely. When an addendum is made it may be necessary to also verbally communicate this information to appropriate care givers. For example, an addendum reflecting an allergy is not something that should be slipped into the patient’s medical record without verbal communication to subsequent care givers and review of the previous care provided to see if there are any implications.  

After an adverse event some caregivers become paralyzed and don’t document anything or document days later. This practice is interpreted as self serving and can do nothing, but chip away at your credibility. Post an event, communication is paramount--verbal and written communication. The record needs to reflect objectively what happened, what was shared with the patient, patient’s response, and the plan of action or intervention needed to address the event. As with any note, facts only. 

Documentation is only as valuable as the legibility of the note. If a note is not readable due to penmanship or articulation then it serves no purpose and can do more damage. The first thing done in court is to enlarge the medical record and have the author of given note read it. Countless times, care givers have not been able to read aloud what they authored in the medical record. This serves also to chip away at the credibility of the provider.

Abbreviations have lead to many a medical error. Each CKHS hospital has a DO NOT USE abbreviation list as well as an approved abbreviation list. Get familiar with it and use it.  No exceptions, no excuses. This also applies to discharge instructions. Patients do not understand qid, bid, etc. Often patients are re-admitted because they did not follow prescriptions/treatment plans for lack of readability or comprehension. The burden is on you to communicate better.

On a final note, document all interactions with or about the patient, face to face or over the phone. The record serves as a log of  communication providing insight into what was said, when it was said, specifically to whom it was said, and their response. You don’t want patients saying, “I never saw a physician the whole time I was in the hospital.” You don’t want patients blaming you for a bad outcome when their non-compliance played a role in their health.    

The well-documented chart is all about continuum of care. As a bonus, it leaves fewer openings for the forensic reviewer to allege you failed to do or consider an important task or finding. A well-documented chart can serve as an independent witness to the care provided.