Tips to Ensure Documentation Accuracy

December 19, 2017

Here are some 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.

1. Never ever use a copy forward note. It just begs to be wrong. It is so easy to pull in a ton of information that was accurate three months ago but which is no longer true. Are you really going to carefully edit that content to make sure it is accurate?      

2. Do not use an exam template that is defaulted to normal. Put stops in the template function that force you to take some action to demonstrate that you stopped and reviewed the exam. If you do use a template, think carefully about what you auto-select. I've seen an astonishing number of notes documenting normal tympanic membrane mobility as part of the exam on older adults. Really? I don't think so.

3. If something is abnormal, stop and document. Jot a quick note to yourself or type in the abnormal exam into the computer. It only takes a moment and improves the likelihood that you will accurately capture the exam.

4. Take the time to make sure documentation is right. Clinic days can be hectic and harried, but it is worth it to you and to your patients to compose the most accurate notes possible.