Skip to main content

MED

Documentation Do’s and Don’ts

Aug 21, 2019 07:00AM ● By Alyssa McGinnis

By COPIC’s Patient Safety and Risk Management Department

One of the most important elements in the defense of a medical liability claim is the patient’s medical chart. If the documentation is accurate, objective, legible, timely, comprehensive, and free of alterations, it will reflect quality care rendered to the patient. Conversely, if these elements are not present, the plaintiff’s attorney could suggest willingness on the part of the physician to carelessly endanger the patient. The following are “best practices” and “things to avoid” when considering proper documentation.

BEST PRACTICES FOR DOCUMENTATION

  • Confirm that items generated from lists, check boxes, etc. are what was intended

  • Be familiar with the content of any templates you use

  • Double check results of drop-downs, templates, auto-complete, etc.

  • Be judicious when using “copy” and/or “paste” and carefully edit and remove irrelevant or unintended content

  • Have a way to incorporate relevant email and text messages into the EHR

  • Record facts in an objective manner; avoid needless commentary

  • Minimize use of abbreviations and have an approved list of abbreviations

  • Correct errors in the record in a way that makes evident who made the change and when

  • Read all providers’ progress notes and all staff notes

  • Recheck decimal points

  • Document discharge instructions

THINGS TO AVOID WITH DOCUMENTATION

  • Clone notes

  • Import content without reviewing it

  • Let automatic “copy/paste” become a regular component of your system

  • Select “something close to the right choice” from a list, if the correct choice is not available

  • Chart non-medical information (e.g. call to your medical liability carrier, attorney, peer review activity, incidents)

  • Criticize other medical personnel

  • Edit, delete, or modify documents if you receive a record request or subpoena