Risk Refresher: Documentation

Write every note like it could be read by the patient and presented as evidence in a court of law.

Risk Management

Risk Refresher: Documentation

No matter how experienced you are as a practitioner, some concepts are worth re-visiting from time to time. Any defense attorney will tell you that many a lawsuit has been thwarted by good documentation.


That’s why it is essential to know your state laws and write every note like it could be read by the patient, the patient’s spouse, his or her attorney and even a jury panel or review board.

 Ensuring Legally Credible Documentation

  • Timing. Document the care when it’s provided. Be sure to always note the time and date. This is especially important during an emergency.
  • Accuracy. Indicate exactly what you did … and only what you did. Inaccurate statements aren’t helpful.
  • Avoid exaggeration or untruthful comments.
  • Treat patients as people, not clinical conditions. Avoid adverse comments about the patient. View your patient as a unique individual with a distinct set of cultural values, beliefs and attitudes.
  • Write what’s important. Your recordkeeping can become your primary defense in a possible lawsuit. When an attorney reviews for consideration of litigation, you don’t get to explain them. That makes it important to ensure your notes are clear, concise, precise and legible.
  • Include a follow-up plan. State what’s important for the patient to do once they leave your office. If consultation or referral is needed, that should be indicated. And be sure to make all appropriate referrals and document them.
  • Don’t be judgmental. Record patients’ statements accurately. Use direct quotes when possible, especially regarding chief complaints.
  • Never alter a patient’s records. Not only is it a criminal act, but altering records also can be especially devastating if done after a lawsuit is filed. Sign and date every entry. There should be no doubt who wrote the note and when.

Your documentation may be the only thing between your word and that of a patient’s. Often your documentation may be the sole item of evidence in a case. 


The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.