Common Documentation Mistakes (And how you can avoid them)

By Stephen M. Savoie, D.C., F.A.C.O.

Naturally, you strive to provide your patients the best of care. It should be enough, but unfortunately, it may not be if your recordkeeping isn't top-notch as well. It's been my experience that making the following common documentation mistakes can put your practice at risk in the event of a malpractice allegation:

1. Altered records. Records should be kept in ink, preferably black, so that clear copies can be made when necessary. How should doctors correct records if a lawsuit is filed? They shouldn't — records should never be altered. Malpractice attorneys often hire expert document examiners to analyze chart notes when it appears a record may have been changed or a post-entry note added (including sophisticated analysis of the ink appearing on the original). There's no faster way to damage your credibility in court than for a plaintiff's attorney to stand in front of a judge and jury and prove you lied. Once notified of a legal action the record should be sealed and no changes made. 
2. Entries not dated or identified. Chiropractors see some patients for many years.  Be sure to identify the year along with the patient's name or identifier on each page of the record. When this is not done, errors can be made during photocopying. It's not unheard of for pages — or even different patient records — to be merged together.
3. Obliterated entries. Mistakes in the record can happen in any office. How they are corrected is important. Always draw a line through the incorrect entry, write the correct information and initial and date the correction. This makes clear what was originally written and what was added. Never use white-out or scribble over the entry because it fuels suspicion about what the original entry might have been.
4. Entries not signed, or signed or countersigned without having been read. Never send out dictated records without having read them. You have no idea what many have happened during the transcription. Two records may have run together, an entry may have been left out or irrelevant information added by the transcriptionist.
5. Entries for care performed without signature. Always indicate who provided care to the patient and include a signature recording the author of the entry. Even if you are a solo practitioner, it is good practice management to initial the daily note.
6. Illegible records. Doctors are notorious for poor handwriting and the point of many jokes. The real point is that records must be able to be read by another provider of same license. A situation may occur when you might be unavailable to care for your patients. In that case, a replacement doctor must be able to read and understand your records to provide proper and necessary care.
7. Lots of blank spaces on the page. Busy doctors sometimes need a form that provides memory prompts so nothing is forgotten. And there are valid clinical reasons for leaving a space blank. However, if a form is continually 90 percent blank, move frequently used items to another form and eliminate the unused form.
8. Uncommon abbreviations. Abbreviations are a wonderful tool and can save time in writing daily records. But if you make up your own, you'll need to send out a legend every time you send out records. Use standard abbreviations.  
9. Failure to document patient noncompliance. All doctors have experienced a patient who is noncompliant and felt the need to discharge them from care. Be sure to document the episodes of noncompliance, whether it is missed appointments, frequent cancellations without rescheduling, failure to do recommended exercises or refusal to stop certain activities (work or sport related).  This documentation can be critical if you are later accused of abandonment.
10. Not documenting phone calls. We have all received calls from patients who are in some distress and need advice on what to do. The advice may be a recommendation to lay in a fetal position with ice on the low back or to seek assistance from an emergency department. In any event, it is a clinical encounter with a patient and must be recorded. In an extreme case it could be the last encounter before a lawsuit is initiated. 
11. Charting only the abnormal. When doing an examination on a particularly busy day, a doctor may be tempted to record only those abnormal (or positive findings) in the record. This can be a dangerous practice. Although abnormal findings are important to determine a diagnosis, negative or normal findings are equally important because they can help rule out serious conditions. For example, the fact that a patient had a negative (normal) SLR, negative Supported Adams Test, negative Bechterew's Test, negative Valsalva Test, normal motor strength, normal peripheral sensation and normal deep tendon reflexes rules out intervertebral disc injury.
12. Test results that do not have a clinical rationale, evidence of review by the doctor or patient notification. Clinical records must include: your reason for ordering a test, test results, a description of how the patient's care was affected and an indication the patient was notified of the results.
13. Insufficient information regarding home care (such as exercise).  Be specific when giving patients instructions for home care. If patients should use ice, tell them how much to use, how long to use it and how to apply it. If you provide exercise instructions, be sure to include details such as the specific number of repetitions and sets to be performed.
14. No date noted for follow-up care. Always note when a patient should return for follow-up care. If a patient is told to call the office when care is needed, be sure to indicate that in the records. When no date for follow-up care is noted in your records, a plaintiff's attorney could allege this is evidence of abandonment. If the patient is being discharged, be sure to document this in the records.
15. No note regarding informed consent discussion. All patients must be provided with sufficient information to enable them to make informed decisions about their care. In my opinion, this does not always require a separate document be signed. However, the doctor must at minimum record that a discussion took place and the patient consented to the care.
16. Notes written more than 24 hours after care was provided. Daily records must be contemporaneous — written as close to the time the care was provided as possible. The more time transpires, the less detail and accuracy are assured. Ideally, daily notes should be completed before leaving the office for the day.
17. No documentation of care provided to other physicians' patients. When you provide care for a colleague's patients during an illness or a vacation, it's still necessary to complete documentation on the care provided. It doesn't matter if you see a patient one time or 20 times, documentation is still required.  Remember, it only takes one visit to initiate a malpractice allegation.
18. No documentation of patient education provided. Chiropractors offer many different levels of patient education — everything from verbal explanations to brochures to videos and DVDs. Documenting that this information was offered to the patient shows the patient was educated about his or her condition.
19. Failure to perform follow-up examinations.  Follow-up examinations allow you to document your patient's improvement or need for additional testing, care or referral.
20. Different levels of documentation for different financial categories of patients. Some in our profession use different levels of record keeping depending on the category of the patient. For example, patients who were involved in auto accidents may have detailed dictated records; those with third-party insurance may have preprinted forms completely filled out; and cash patients may have an entry that includes the date, symptom and an indication to return in two weeks. When you provide the same level of chiropractic care to your patients, you should use the same level of recordkeeping.

    Stating that a patient is "crazy" could be interpreted in a variety of ways ...

21. Use of subjective, rather than objective, language. Stating that a patient is "crazy" could be interpreted in a variety of ways and isn't particular useful to other health care providers who read the record. Describe as precisely as possible the patient's condition and the care you rendered. It's perfectly clear when you state that a patient is uncooperative and belligerent, but calling them a pain in the neck could be difficult to explain to a jury.
22. Critical remarks about other providers.  The patient record is not the place to critique your colleagues. Stating that another provider did something wrong could embroil you in someone else's malpractice lawsuit.
23. Egotistical remarks. Don't boast about your accomplishments in a patient's record. Remember, if you take credit for the good, you'll have be equally responsible for the bad. Never guarantee a cure because it can come back to haunt you.
24. Making patients sound sicker than they are. Record your patients' conditions accurately. Don't make them sound sicker — or healthier — than they are. Some physicians have admitted to falsifying records to justify treatments or tests with managed care organizations. This is not a group you want to join. Just as in court, your records should tell the truth, the whole truth and nothing but the truth.

    Never guarantee a cure because it can come back to haunt you.

25. Contraindications to certain procedures or therapies buried in the record. If there an adjusting procedure or therapy that could have a detrimental effect on a patient, don't write it on a small post-it note and stick it in the back of the chart.  Place this information where anyone will immediately see it when opening the patient record. 
26. Records that don't change over a series of office visits. Due to the frequency with which chiropractors need to see patients, especially in acute phases of care, the daily record may be very similar or even identical over a span of two or three visits. When the daily notes are virtually identical over a greater number of visits, it invites closer scrutiny. Records that don't change indicate a patient is not making progress, and if the patient isn't making progress, why are they continuing to receive chiropractic care? 
27. Squeezing information in between two previous notes. On occasion a doctor may forget to include a daily entry only to find the omission after one, two or three visits. In this case, don't try to squeeze several lines of information onto a single line. Go to the next blank space, write the day's date, and make your entry indicating the date of service. Yes, it's out of sequence, but it can be explained. 

Proper documentation can improve patient care, make your life easier and protect you in the event of a malpractice allegation. If you noticed any areas for improvement in the list above, refer to the tips at right for guidance.

Stephen Savoie, D.C., F.A.C.O., is a graduate of Palmer College of Chiropractic and has completed postgraduate programs in sports chiropractic and chiropractic orthopedics. A fellow of the Academy of Chiropractic Orthopedists, Dr. Savoie also serves on the Academy's board. In 2000, he returned to fulltime chiropractic practice in Clermont, Fla.

References: The 25 Warning Signs of Poor Documentation, Susan Keane Baker, American Medical News republished in Medicare Part B Special Newsletter, July 1996. Contributions from Risk Management and Record Keeping, An online continuing education, Stephen M. Savoie, D.C., F.A.C.O., Palmer Institute for Professional Advancement.

This article is not offered as legal advice. Please consult your attorney regarding legal issues impacting your practice.