All physicians know a medical record must be maintained on each patient. Why? Medical record documentation is required by state and federal laws. Proper documentation is important for continuity of patient care and necessary to receive reimbursement for services rendered. The patient’s medical record is a legal record of the care you provide to the patient and is a valuable tool in your defense should a medical malpractice lawsuit be brought against you.

Many electronic health record (EHR) systems were developed to provide documentation required for reimbursement purposes. While reimbursement is important, documentation can also be a meaningful way to enhance patient care, which benefits both you and the patient.

Below are some ways to help you make your documentation more meaningful.

Create A Unique Record of Each Patient’s Visit
Be aware of an EHR’s auto-populate function and templated notes. If information from the initial or a previous visit is carried forward, make sure the information can be over-ridden if the information is no longer applicable. For example, if the initial history and physical examination findings are carried over to future visits, it appears that the initial history and physical examination was performed at each visit.

Make sure that documentation of each visit is specific for what occurred during that visit. If you use templated notes, review the note to be sure the information is correct for that patient. Inaccurate medical records can lead to poor patient outcomes, confusion for subsequent providers, investigations resulting from audits, and can make it difficult to defend your care if called into question via a lawsuit.

The patient’s medical record should contain a clear picture of the patient’s journey through your care from start to finish. What was the patient’s condition at the first visit? Did the patient’s condition improve or worsen during follow-up visits? What did you do for your patient on each visit? Was the patient and/or family involved with their treatment? What was the patient’s condition at the last visit? 

Correct, Amend, or Make a Late Entry Correctly
Review your entries for the day and make sure they are accurate before authenticating the record. It is much easier to make sure a record is correct than to have to make a correction later on. Should you determine an authenticated entry needs to be corrected or amended or that a late entry needs to be made, it needs to be done in a way that avoids any appearance of medical record alteration. Alteration of a medical record can have serious consequences, including allegations of fraud and professional misconduct.

Any correction, addendum, or late entry should be made in a timely manner. Delays in revisions could call the credibility of the revisions into question. Include the date and time of the revision, the name of the person making the revision, an explanation of what information was changed or added, and the rationale for the revision. Your EHR system should not allow revisions to overwrite the original content – the original content should be easily accessed. If the revision is not next to the original entry, there should be a note by the original entry stating that a revision exists and how to locate the revision.

It is important to note that no revisions should be made to a patient’s medical record after an attorney or governmental agency makes a request for medical records because any revisions could be viewed as self-serving. Talk to your claims specialist and defense attorney if you have any concerns about the content of the record and they can advise you regarding the best course of action.

Update Problem and Medication Lists and Allergy Information
These lists can be sources of current and comprehensive patient information and valuable tools for clinical decision-making. However, if they are not kept current and updated, they can be a source of confusion or error. Has the patient really been taking antibiotics for a year? Does the patient really have a non-healing wound on the right foot when the patient had an amputation below the right knee after the non-healing wound failed to heal? Has the patient had an acute sprain for over a year? When lists are not updated, it creates inconsistencies in the medical record. Such inconsistencies not only create the potential for patient harm, but also reduces the credibility of the physician.

It is also important to keep the patient’s allergy list updated to reduce the chance of an adverse event such as an allergic reaction to a medication that was prescribed because the allergy list was not updated. Review and update the patient’s allergy history at each visit and prior to prescription refills.

Document Phone Calls, Emails, and Non-traditional Patient Encounters
It can be easy to forget to incorporate documentation of phone calls, emails, or other encounters with patients, caregivers, and other healthcare providers outside of an office visit. Make sure that all communications with, or regarding, your patient are documented in the patient’s medical record. Memory can fade with time, and if the encounter was not documented, it can be difficult to defend allegations of malpractice made by a patient.

Document Your Thought Process Regarding Your Treatment Decisions
There can be several treatment options, but you consider a patient’s history, co-morbidities, lifestyle, and many other factors when recommending a treatment plan for your patient. There is always a risk that the patient will have an adverse outcome or not respond to your chosen treatment. Should a lawsuit develop, a common allegation is the physician ordered or performed inappropriate treatment and did not consider other treatment options. It is much easier to defend if you contemporaneously documented your decision-making process. 

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“OUM” and “OUM Chiropractor Program” do not refer to a legal entity or insurance company but to a program or symbol of a program underwritten, insured, and administered by ProAssurance. The information contained on the OUM Chiropractor Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.