Accurate Medical Records: Your Primary Line of Defense
Every medical malpractice suit can be won or lost based on the quality and content of the medical records.
A suit without merit can be lost because the medical record was vague, incomplete, or altered. Conversely, a potentially damaging suit can be won because the medical record was precise, thorough, and accurate—and events were well documented.
The Doctors Company is adamant about the critical need for every physician to maintain meticulous records. If you are faced with a malpractice claim, your record keeping will help us provide the best possible defense.
General Guidelines
The following general guidelines should be observed when completing a medical record:
- Ensure medical record entries are clear and readable. If possible, dictate all long entries that require more than brief or routine annotations.
- Include a detailed and accurate medical history, physical findings, differential diagnoses, treatment plan, care rendered, advice given, and all other matters pertinent to the patient’s medical course.
- Never squeeze words into a line or leave blank spaces. Draw diagonal lines through all blank spaces after an entry.
- Never erase, write over, try to ink out, or use whiteout on an entry. In case of error, draw a single line through the incorrect entry, and write the date, the time, and your initials in the margin.
- Never add anything unless you write a separately dated and signed note. The patient, a third-party payer, or a plaintiff’s attorney may have obtained a copy of the original records.
- Always indicate the date and time of an entry. Ensure each page includes the patient’s name and that each progress note is accompanied by the date and time. Make certain all entries are initialed or signed.
- Avoid personal abbreviations, ditto marks, or initials. Use only standard and accepted medical abbreviations.
- Do not use lengthy, self-serving entries. These may appear defensive in nature when explaining a complication or medical catastrophe.
- Do not use the patient’s record as a place to record confidential communications between you and your professional liability insurance carrier or your attorney—or to criticize another caregiver.
- Always keep a record of when and by whom your medical record is photocopied.
Using Specific Language
Avoid imprecise language, generalizations, and the use of statements that are subjective rather than objective.
- Imprecise: Doing OK.
Accurate: Less pain today. Ate full diet. - Subjective: Appears depressed.
Objective: Crying and worried about progress. - General: Wound OK.
Specific: Surgical incision healing. No sign of infection.
- See: Color, abnormality, posture.
- Smell: Breath, drainage, excretions.
- Hear: Sounds of breathing, crepitation, bowel sounds.
- Feel: Hot or cool, dry or moist, soft or firm.
- Incorrect: Patient apparently fell.
Correct: Patient states that he “tried to get up, tripped, and hit head on the corner of the bed.”
- When absent from practice, include the name of the physician you have signed out to and the date and time you signed out, pertinent observations, and follow-up of any abnormal situation.
- Justification of your failure to comply with—or your rejection of—a consultant’s advice.
- Your viewpoints and reasons for any disagreement on patient care between you and a hospital utilization review committee, a preferred provider organization, or a managed care receiver.
- Explanations of delayed responses to a nurse or house staff calls, including dates and times.
- Responses to nurses’ pertinent observations of a patient. (Be sure to record follow-up in your progress notes.)
- A patient’s negative reaction to any treatment or medication.
A Checklist Helps to Protect You
The following entries should appear in the office or hospital records of each patient:
- Results of a patient’s physical examination, specifically noting the absence of abnormality.
- Patient history, a list of all medications with particular emphasis on current medications, to include over-the-counter drugs and supplements and any allergies or drug sensitivities.
- Specific notation on the patient’s experience, if any, with drug or alcohol abuse and family or emotional problems.
- Progress notes, entered after each office visit, about any change in status. (If negative, your follow-up should be indicated.)
- Signed and witnessed consent forms for special procedures or surgery.
- Patient response to medication or procedures.
- Patient failure to follow advice or to keep appointments and any refusal to cooperate. (Log missed appointments and follow-up telephone calls and letters.)
- All significant laboratory or x-ray reports and the dates when they were ordered and read.
- Copies or records of instructions of any kind (including diet) and directions given to the family.
- Records of consultations with other physicians and their written or oral responses, with the dates and times.
- Thorough documentation of any patient’s grievance, including the date and time.
Patient Care Instructions
- Always record your instructions in writing.
- Review your instructions with the patient and the patient’s family.
- Ensure comprehension. Use a teach-back method to ensure that the patient can accurately describe his or her treatment plan. Record the patient’s response.
- Document language limitations and attempts made to overcome them through the use of translators, as well as any questionable comprehension. Note any literature provided to the patient and family.
- Retain a copy of instructions given to the patient and family.
- Note patient failure to comply with instructions and your efforts to inform the patient of the risks of noncompliance.
Instructions to Include (When Applicable)
- Specific wound care.
- The amount of incisional bleeding to be expected.
- Limitations of activity, position, or exercise.
- Dietary restrictions.
- Specific instructions for medications, including possible side effects and when to resume preoperative medications.
- Anticipated postoperative pain and time frames for analgesia.
Conclusion
As a company built by doctors for doctors, we are fiercely committed to helping you minimize risk. Your medical records are a vital part of your defense in the event of a claim. Using these guidelines is crucial to your protection and defense.
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About the Author
This article, published in 2003, was updated in 2008 by Governor Emeritus Mark Gorney, MD, FACS, Paula A. Jenkins, Senior Vice President of Claims, Laura A. Dixon, BS, JD, RN, CPHRM, Director, Department of Patient Safety, Western Region, and Susan Shepard, MSN, MA, RN, Director, Patient Safety Education.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.