How to ensure documentation accuracy


Tips physicians should be using to ensure accurate documentation while protecting their professional integrity.

A number of years ago, I had a patient in the hospital with a weird neurologic sign, and it was unclear whether it was new or old. I undertook an exhaustive search of her medical record, hoping to find evidence in previous office visit notes and exams to indicate the timeline of this particular issue.

It turned out that it had been observed previously, but not continuously (as would be expected). Multiple interval notes documented a completely normal neurologic exam. Interspersed in these records were what I suspected to be the accurate exams documenting the abnormal examination.

I thought of this recently as I reviewed notes in the electronic medical record (EMR) documenting things like a completely normal and quite thorough neurologic exam on a patient being seen for a cold. One of my colleagues has a great example from an ER note in which one of her patients was being seen for an ankle injury. The note was impressively and extensively complete with a fully documented physical exam with the exception of – you guessed it – any musculoskeletal exam.

It's so easy to document much more than we actually did. It is also incredibly easy to document a normal exam as part of a default template. However, these acts of inclusion and omission represent a significant threat to patient safety as well as a challenge to our professional integrity as physicians.

It is easier than ever to construct a multi-page note which uses hundreds of words without conveying a single piece of relevant information. The EMR allows us to pull all kinds of information into the record without having to review or read any of it. We can drop detailed examinations and plans into the note with a few keystrokes. Brevity and accuracy have been sacrificed for efficiency and completeness. This is dangerous – it puts both patients and physicians at risk.

There are a few things physicians should do to ensure the accuracy of their notes and guard their professional integrity.