Risk Management — Hard Copy Records Best Practices
Medical malpractice claims can be won or lost based of the quality and content of the medical record.
It is essential that the medical record accurately document everything a physician does with regard to evaluating, managing, and treating a patient—and it is particularly important to document the rationale for critical decision making. If there is poor documentation or if the medical record is vague, incomplete, or altered, the defense of a claim will be compromised and frequently results in settlement or loss. Furthermore, since claims are often filed years after an event occurred, a physician may not remember the case in sufficient detail without a detailed medical record to review.
Hard Copy (Paper) Records
For written medical records, entries should be legible and in ink. Each entry should be made with the same pen to avoid any suspicion that information was subsequently added. Illegible entries, contradictions, factual errors, and especially the appearance of altered records are repetitive problems. If the medical record is or appears to be altered, a jury may conclude that the doctor was attempting to conceal an error. On the other hand, any inaccurate information left in the medical record can also result in liability. If such an entry or an error is discovered, draw a single line through the entry/error, then initial and date it. Do not write over the entry to make it illegible, attempt to erase it, or use white correction fluid. Never squeeze words into a line or leave blank spaces between entries. Draw diagonal lines through the blank spaces.
Late entries, especially if they augment sparse notes and are written in the margin of the page, can raise questions of retroactive tampering with the record. It is preferable to make a late entry in an empty space on the notes page, indicate the date and time, explain why it was entered late and is therefore out of sequence, and cross-walk it to the appropriate place in the record using asterisks or arrows. Never add anything to the medical record unless you write a separately dated and signed note. Similarly, late dictation of an operative report can raise questions—especially if a complication occurred during surgery. And if you become aware that a malpractice claim may be filed, do not add a lengthy late entry justifying a treatment, diagnostic conclusion, or adverse outcome because it may appear self-serving and a jury may doubt that such detail can be recalled accurately.
Experts on document examination can detect virtually any alteration of or addition to the medical record—and deliberately altering a medical record is illegal and can lead to criminal charges, disciplinary action, loss of license, and fines.
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 healthcare 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.