Beyond the checkbox: The power of proper documentation

Medical documentation, frequently perceived as a mere “checkbox” task, is, in fact, a pivotal factor in delineating a patient's healthcare trajectory. This role underwent a transformation with the advent of the "open notes" provision of the 21st Century Cures Act in 2021. While the Act pursues the commendable goal of fostering patient engagement through increased access to medical records, it also brings to light unanticipated risks, such as premature disclosure of diagnoses or breaches of confidentiality in sensitive situations like domestic abuse. In this evolving landscape, physicians and practice leaders are presented with a golden opportunity: By truly mastering the art and science of documentation, they can enhance patient care, facilitate communication, and defend against potential malpractice claims.

Two cases underscore the critical role of documentation in healthcare. In one, an individual with a documented penicillin allergy experiences cardiac arrest after receiving a cephalosporin injection, a reaction to a previously undocumented adverse event. In another, an elevated PSA level, left uncommunicated and undocumented during a routine check-up, results in a delayed prostate cancer diagnosis and post-operative sexual dysfunction. Both situations led to malpractice claims. Expert medical documentation, by methodically capturing diagnostic decisions, treatment plans, and consent discussions, could have improved clinical communication and provided a protective layer against malpractice allegations.

Avoiding pitfalls

Plaintiff's lawyers utilize medical records to establish the duty of care, determine damage extent, identify responsible parties, and infer care quality. Poor documentation can lead to an assumption of substandard care, further underlining the need for physicians and practice managers to understand these common documentation pitfalls and devise strategies to circumvent them.

Ignoring the basic principles: Fundamental principles include legibility, particularly for handwritten records; accuracy, which avoids patient risks and malpractice suits; objectivity, steering clear of judgmental or subjective phrases; and timeliness, as entries need accurate time stamps to negate delayed care claims. Authentication and attestation matter in legal proceedings, with any changes treated seriously and corrections properly made. Adverse events should be documented objectively without admitting error, blaming others, altering records, or including inflammatory comments about patients or providers.

Neglecting to document negative findings: In the healthcare industry's daily hustle, it's easy to gloss over the absence of pathognomonic symptoms, noncompliance, missed appointments, and lack of pain. However, this seemingly innocuous omission can be a game-changer in the context of a malpractice claim. Negative findings often provide a comprehensive view of the patient's condition and guide treatment decisions. Therefore, healthcare professionals should make it a practice to document not just what's present but also what's absent.

Inadequate diagnostic documentation: The narrative leading to a diagnosis can sometimes be as important as the diagnosis itself. Documenting the thought process, the considered differential diagnoses, and the reasons for the chosen treatment can guide future care and provide valuable defense in a malpractice case. In the face of clinical uncertainty, transparency in documentation can underscore the diligence and thoroughness of patient care.

Misuse of electronic health record (EHR) features: EHRs offer time-saving templates and drop-down options, but misuse can lead to note “cloning” or incorrect documentation. For example, a 2022 analysis of the University of Pennsylvania Medical Center's EHRs revealed that over half the content of 100 million notes was duplicated. Similarly, a study found that 80% of 24,000 notes by 460 clinicians had copied or imported content, risking outdated or incorrect information. This practice can compromise patient care and attract regulatory scrutiny. To mitigate this, audits and double-checking EHR entries should be standard practice.

Improper documentation of informed consent or refusal: Informed consent stands as a pillar of ethical medical practice and is much more than just a form—it's a process. Amid the pressing demands of patient care, documentation of this critical process can often be sidelined. In fact, analysis reveals that inadequate informed consent played a part in a significant 44% of adverse events where provider-patient communication was implicated. A thorough informed consent discussion should encompass an explanation of the proposed procedure or treatment, its benefits, risks, and alternatives. This discussion should be thoroughly documented and reflect the patient's understanding and voluntary agreement. In the event of a legal claim, this level of detail, accompanied by a signed consent form, stands as a powerful affirmation of patient autonomy and professional integrity.

Poor follow-up on test results: All too often, the key contributor to diagnostic errors—the leading cause of medical malpractice claims—can be traced back to mismanaged test results. When we dig deeper, the significance becomes clearer. An examination of five years' worth of closed diagnostic error claims revealed that an alarming 62% of incidents and 59% of paid indemnities were linked to the mishandling of test results. The implementation of a robust, dependable system for test result reviews and prompt patient communication can serve as a safety net, catching critical information that could otherwise slip through the cracks. Documentation should reflect these follow-up actions to ensure transparency and accountability in patient care.

Innovative approaches

Groundbreaking solutions are emerging to refine and augment medical documentation.

Clinical decision support systems—where artificial intelligence meets the EHR—are supporting diagnoses and treatment decisions, curbing the risk of diagnostic mishaps caused by human lapses. Further, computerized physician order entry systems are reinventing the prescription process, significantly enhancing documentation precision, and minimizing medication errors.

In today’s patient-focused era, spurred on by the 21st Century Cures Act, medical documentation has evolved from an administrative task to a pivotal tool used to strengthen connections between patients, providers, and the overall healthcare system. Physicians stand at the heart of this transformation, with each note they write performing a dual role—illustrating each patient's unique health journey while also serving as a solid defense against potential malpractice claims.

Indeed, effective medical documentation reflects each healthcare professional’s dedication to patient care, their commitment to ongoing improvement, and their professional integrity. It's more than just a bureaucratic requirement; it's a key driver of change and a bedrock of trust within healthcare. In this way, medical documentation assumes a powerful role in shaping the contemporary healthcare landscape.

Marlene Icenhower BSN, JD, CPHRM is a Senior Risk Management Specialist at Coverys with more than 30 years of combined medical-legal experience in a variety of settings. With a background in professional liability litigation and regulatory compliance, Marlene has extensive experience advising clients in the healthcare industry regarding compliance with state and federal laws and risk reduction techniques.