In healthcare, it’s critical to have complete, accurate, legible, and secure documentation in medical records to help reduce the risk of lawsuits. Whether records are handwritten or electronic, there are necessary steps to take with each and every patient encounter. Here are 5 specific ways proper documentation can prevent patients from suing their healthcare provider.
#1 Accurate Documentation
Documentation must always reflect the physician’s examination of the patient, diagnosis and treatment plan as well as the follow-up if prescribed. If the exam cannot be verified, the quality of care cannot be supported. Documentation is also required to justify reimbursement. With the focus of the Office of the Inspector General (OIG) on fraudulent billing practices, the accuracy of the documentation will prove the services provided were provided at such a high level, that payment is not in question.
#2 Legible Documentation
All documentation must be legible to anyone who may read it. Providers who have poor penmanship, need to print. With electronic medical records, there are still concerns about details such as timeliness of documenting, spelling or simple errors in copying and pasting when making corrections. It’s necessary that the full name and credentials are on documentation forms. A signature page needs to be filed in each chart. The signature page lists the staff member’s name, title and signature. If anyone accessing the information wants to contact the professional, there is a form in the chart that will identify the author.
#3 Secure Records
Here are some tips for maintaining secure records:
- Never share your password. Tell your immediate supervisor if someone is using your password.
- Don’t leave personal health information displayed on the computer screen. Log off the computer when you’re not using it.
- Retrieve any printouts immediately.
- Follow your facility’s policies and procedures for computer entries and error corrections.
- Refresh your knowledge of the latest HIPAA regulations annually.
- If you are using a laptop to document at work and you are allowed to take it home with you, do not be tempted to let members of the family use it for personal reasons.
#4 Never Improperly Alter a Chart
The one thing that can destroy even a fully defensible case is evidence of improper chart alteration. The following admonitions are designed to prevent even the appearance of a chart alteration:
- If you need to remove or change data in the chart, do not erase the data but put a line though it so it is still readable, then sign and date the change.
- Never, under any circumstances, succumb to the temptation to make additions to the chart after a suit is threatened or filed in an attempt to make your alterations appear to have been made at the time of the original note. It is not uncommon for a patient or lawyer to obtain a copy of a chart before filing suit and then obtain another copy after filing for comparison.
- Suspicious changes are deadly to a professional liability case. If, after being sued, you see a mistake in the chart that should be corrected, discuss the matter first with your attorney.
#5 Avoid editorial comments
Unless they are medically necessary to improve care, don’t make editorial comments to the patient. All interactions should be professional and factual. Editorial comments may be used against a provider to portray him or her as an intolerant physician who shortchanged a patient due to a personality conflict. Where patient behavior does affect care, it is important to document it, however do not use lengthy self-defensive entries in charts to try to explain a medical mishap. Writing self-defensive entries adds nothing to the patient’s care and only portrays you as defensive. Stick to the facts.
Bottom Line: At the heart of it, the medical record exists to facilitate the communication of factual information about a patient to be used among their care team. As such, the record should be timely, accurate, complete and secure. Not only does this ensure that patients are receiving the best possible care, it also reduces the risk of lawsuits.
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