Medical Documentation That Matters; Separating the "Signal" from the "Noise" in EHR Documentation
By Alan Lembitz, MD
In the last 20 years with the institution of electronic health records (EHRs), the time it takes to complete medical documentation has gotten longer and longer. It’s not unusual to see a short and routine emergency department visit for an ankle sprain result in a multi-page note.
But more documentation isn't necessarily better. In fact, studies demonstrate how current medical documentation includes a lot of “noise,” without necessarily identifying the key “signal” that is important.
There are several reasons for medical documentation, but this article will focus on the following:
Documenting the services, thought processes, and recommendations to determine that the provider was practicing within a reasonable scope of practice when complaints at the licensing board or legal liability actions arise.
This point is about establishing that a given encounter was within the range of acceptable practices, or the “standard of care.” More volume of documentation generally does not serve the point’s purpose well, but in many cases specific documentation is critical to defense. We often are looking in retrospect when care is in question for these very important “signals” which can be lost in the “noise.”
Considerations for All Clinical Encounters
Detailed documentation of informal and curbside consultations by both the requester of the consultation and the provider of it are often missing or inadequate. The documentation should include the information conveyed, the decisions made, and who was assigned responsibility for the patient’s care, now and in subsequent follow-up.
Incidental findings require someone to “close the loop” with the patient about the nature of the abnormality, including why the recommended follow-up is important and the risks of not following up.
Trusting the next clinician to provide the necessary follow-up on the incidental finding is often inadequate. Informing the patient and documenting the critical elements greatly adds to the defense when the patient alleges they were never told, and so suffered an adverse outcome such as a delayed diagnosis of a now more advanced malignancy.
When you receive critical lab, imaging, and other diagnostic findings, document what you did and what was communicated, including referring the patient for further immediate care. In legal cases viewed retrospectively, families and patients often allege that they stated something completely different than what the clinician or clinical team heard.
One documentation strategy is to specifically state the patient's chief concerns and chief complaints verbatim and in quotes; such as “patient states (or chief complaint or chief concern)…” Recall that a chief concern is different from a chief complaint, but can provide insight into what the patient or family believes to be occurring. When their chief concern turns out to be accurate, and it was dismissed, ignored, or never heard, it can be difficult to defend the care.
High-Risk Reminders Across Service Lines
Alan Lembitz, MD,is with the COPIC Department of Patient Safety and Risk Management
Mentioned previously but deserving of repetition for all service lines is the need for congruent findings and documentation among multiple observers—medical assistants, nursing staff, and other providers. In cases involving adverse outcomes, there is often accurate information or findings by one member of the team that are critical to the outcome, but not widely communicated or documented by the people making decisions. When patients refuse your medical recommendations, we often cannot tell from the documentation whether the clinician described the benefits, risks, and alternatives of that recommendation to the patient. Patients can choose to refuse care after adequately being informed, and for that purpose an informed refusal document may be appropriate.
Critical Documentation for Your Best Defense
Small amounts of critical documentation can often be your best defense. The specific scenarios and strategies for these critical documentation opportunities described previously are not an all-inclusive list, but represent a majority of the preventable issues in which defense of your care could have been enhanced. There is much documentation noise that can serve the other purposes described but have little impact on your defense. We hope to improve the necessary signal, with the understanding of the vast amount of noise that can exist in the medical record.