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13 Common Documentation Mistakes

Common documentation mistakes can put your practice at risk in the event of a malpractice allegation.

You strive to provide your patients the best of care, but unfortunately, that's not enough if your record-keeping isn't top-notch as well. Here are a few common documentation mistakes that can put your practice at risk in the event of a malpractice allegation.

Altering Records

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. Experts can compare the date that was keyed in to the time and date stamp on your hard drive—it's a major red flag if your records don't match. There's no faster way to damage your credibility in court than for a plaintiff's attorney to prove to a judge and jury that you lied. Once notified of a legal action, the record should be sealed and no changes made.

Copying and Pasting Entries or Notes

It may be tempting to save time by cutting and pasting notes when patients have similar conditions, treatments, or instructions, but resist the temptation. Should it come up in a malpractice case, copied and pasted notes look lazy, cookie-cutter, and dismissive of each patient as an individual person with unique issues to address.

Failing to Review Dictation

Never send out or finalize dictated records without having read them. You have no idea how accurate the transcription was. Two records may have run together, an entry may have been left out, or your dictation services could have misheard words or phrases entirely.

Entries for Care Performed without Signature

With EHR systems, ensure logins are properly set and administered so those making entries are easily identified by their logins. 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.

Incoherent Records

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 understand your records to provide proper and necessary care. 

Leaving Too Many Fields Blank

Busy doctors sometimes need a form that provides memory prompts so nothing is forgotten. And there are valid clinical reasons for leaving a form field blank. However, if a form is often left empty because it's not a useful form, move frequently used fields to another form and eliminate the unused one.

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, or don't abbreviate if a common abbreviation doesn't already exist.

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.

Not Documenting Phone Calls or Text Messages

It's not uncommon for a patient in distress or pain to call or text asking for advice. Whether the advice is as simple as applying ice or as urgent as an immediate trip to the ER, calls and texts like these are considered clinical encounters with patients and must be recorded. In an extreme case, it could be the last encounter before a lawsuit is initiated.

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.

Test Results with No Clinical Rational or 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.

Failing to Back Up Records

If your computer gets damaged or wiped out, you should still be able to access your records. Whether it's a cloud-based system, an external hard drive in a fireproof location, or another method of backing up, your records should be stored in a secure secondary location and updated frequently.

Falling Behind on Training

All doctors and staff should be fully capable and knowledgable on all documentation software used in your practice. That includes ensuring that everyone is trained on software updates if and when they happen.

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