Facing challenges in documenting medical care

Every healthcare professional knows that, at some point in their medical practice, they may be called on to defend patient care. When time passes and our ability to accurately recall information is diminished we should be able to rely on documentation of events to answer questions. There are practices you can adopt that can make it easier to make a good habit of properly documenting everything that happens before, during and after patient care.

Documenting everything is not the only key component to keeping proper records. Your medical record entries must be adequate representations of what happened. Imagine a jury reviewing records in a medical malpractice case, assume they do not spend much of their time reading medical records. How might they react to inadequate records? What may be obvious to you may not be to them. When others are charged with judging your credibility, the quality of your medical records can either enhance or diminish your credibility.

Examples of detrimental documentation practices, as identified in the recently article published by The Doctors Company, The Faintest Ink.[i]

  • Gaps and delays in documentation
  • Illegible entries
  • Dictation with blanks
  • Unflattering or judgmental patient descriptions
  • Entries appearing to vent negative feelings
  • Altered records and records missing documents or entries

To ensure proper documentation, each time and every time, the best practice is to develop a system for entering and recording information. Almost like a checklist, you can determine the rules and procedures for managing information. Identify details regarding when, where, how, what and why information is recorded. While it may seem like extra work, at some point your medical records could be under review and read in isolation of other information. Therefore, every single time it is helpful to identify why an entry is being recorded.

Features and benefits of good documentation habits

Increased communication with patients and increased continuity of care should increase understanding, decrease misunderstanding. In many medical malpractice cases, the root of the problem leading to a complaint can often be identified as failure in the communication process.

One way to improve communication is to use dictation equipment to make your patient notes. When you dictate notes right in front of patients you are more likely to read the details into the notes so that the patient can understand everything. If, on the other hand, you are making dictation and sound cryptic or unclear, a patient could become nervous and worried about not having a clear understanding of their doctor visit.

When making entries, beware of the easy mistakes that you can make when using forms and templates. A simple mistake in recording information on a form can cause problems. If there is an error in checking boxes on one form, could there be more errors on other forms? Making independent notes every time you record patient information better insures accuracy and credibility of information.

It is a good idea to audit and review medical records to ensure that documentation procedures are consistently used. In the audit process, a reviewer may detect entries that may require a second look. If there is an error or missing information, it is always best to make a new record and attach it as an addendum to the original. Do not change or alter records when there is active or pending litigation.

For more tips on documenting patient medical records or if you have questions about exposure and liability in the event of a patient complaint or claim for malpractice, please be in touch with Michael V. Favia and Associates, P.C.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.


[i] Source for article summary: The Doctors Company, The Faintest Ink, By Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.