The medical record, apart from being the most important healthcare record, is a significant legal document when it comes to personal injury, medical malpractice, workers’ compensation, and social security disability lawsuits. It is required for medical records analysis to evaluate the injury or disability. Clinical documentation in paper and electronic formats exist in large volumes in healthcare facilities and these records range from physician and nurse notes to transcripts of dictation and more. Accurate and comprehensive documentation will provide the care team with a clear view of the patient’s history, present condition, treatments provided and other important details. It will improve physician-to-physician communication and ensure enhanced patient care. However, “poor documentation” is a sad reality and this could lead to adverse consequences for the physician as well as the patient. Since the medical record forms the basis of argument for the plaintiff lawyer, any inaccuracies and other shortcomings in the record would prove detrimental to the healthcare provider in medical malpractice litigation.
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What Constitutes Poor Medical Record Documentation?
Any record that is unclear, and lacks specificity or completeness will be of poor quality. It constitutes documentation that does not concisely convey a patient’s health problem and the solutions undertaken to address that concern. Precise and complete documentation is vital to obtain the correct physician reimbursement and accurate quality scores. More importantly, only with accurate documentation can you provide accurate information to the patients that is so important when it comes to making informed decisions. Grave consequences of poor documentation include the following:
- Wrong treatment decisions
- Unnecessary, expensive diagnostic studies
- Unclear communication among consultants and referring physicians, which could lead to issues with follow-up evaluations and treatment plans
- Inaccurate information regarding patient care
- Poor patient care
- Cause the physician to lose his/her license
- Lost revenue/reimbursement
- Inappropriate billing that could lead to fraud charges
The consequences of poor documentation are not minor, but they are major and real. Patient safety issues are the main concern among many others. Another chief concern is the financial impact on the healthcare practice. Also, if the documentation is not reliable, you cannot provide proper health information to the patients. The inability to do so can lead to legal hassles among other issues.
What Are the Major Reasons for a Poorly Documented Medical Record?
- Shortage of notes: All details of the consultation with the patient must be clearly recorded in the medical chart. These would include all aspects of care, treatment, preventive measures, testing and so on. If this is not done, the medical chart would be incomplete and inadequate.
- Insufficient medical history of the patient: Physicians should note down each and every detail about the patient’s past medical history, drug use, family history, allergies and names of other providers who are treating them. These details are necessary to prevent hostile events such as adverse drug interactions, allergic reactions, illnesses and so on. If the patient history is inadequate, it could result in patient harm.
- Illegible handwriting: When the handwriting is not clear, the names of drugs may be misread and cause patient harm if the wrong drugs are administered.
- Blank fields: No fields should be left blank in the medical chart. An example would be if a patient has no known drug allergies, the physician may leave the drug allergies section blank. Instead of leaving it blank, the better and safer option would be to record NKDA in the field.
- Inadequate documentation of prescriptions and refills: If the medications prescribed are not properly documented in the medical record, it could result in adverse drug reactions, overdoses, and patient harm.
Insufficient provider education leads to many documentation issues, as many CDI (Clinical Documentation Improvement) experts point out. Often, providers have a lack of understanding of the specific information that must be included for medical coding purposes. Physicians may note down a lot of information but often fail to use the words needed to provide the highest level of specificity. Another reason for insufficient documentation is shortage of time. Busy physicians spend whatever limited amount of time they have on patient care and very often documentation is only their secondary priority.
Another consideration is the electronic health record, which has helped improve documentation but is not yet without problems. The major issue is copying and pasting within the medical records. Providers have to be very cautious when indulging in copy-paste within the medical chart. EHR vendors can work closely with clinicians and medical coders to bring about useful adjustments in the EHR to address existing concerns.
How to Improve Medical Record Documentation?
When the medical record is incomplete, it is proof that the care provided was incomplete or insufficient. Gaps in the chart demonstrate that the clinical care provided was of poor quality. Such inadequate records can be used to support medical negligence and fraud allegations. This calls for efforts to improve documentation. If healthcare organizations are uncertain about their clinical documentation quality, they should perform a gap analysis and compare their position with that of competitors that provide the same type of services. A good CDI program should have the following functions, according to experts.
- Review of the medical records of patients to find out whether documentation of diagnoses is complete or insufficient
- Identify possible patient safety indicators and hospital-acquired conditions. When necessary, query whether or not these conditions were present when the patient was first admitted
- Address the identified documentation improvement opportunities with the provider using compliant queries
- Provide education opportunities to clinicians. The clinicians should be made aware how accurate and complete documentation could improve patient care, and also positively impact their profile
A complete medical chart needs to be clear, legible, and accurate containing all the relevant clinical findings, medical decisions, prescribed drug information, data regarding other treatments and investigations, and the information conveyed to patients. To ensure this, the clinical notes must contain the following.
- Patient demographics
- Exams performed and their scope
- Reasons for current visit
- Findings of the exams
- Treatment and management plan
- Future treatment recommendations
- Drug allergies
- Prescribed medications, renewed medications
- Patient education and instructions info
- Communications with patient’s family and friends
- Advised return visit date
All entries in the medical chart must be timely and prompt; if there has been any delay involved in the time of the event, that should be documented. All entries must be accompanied by the name and designation of the person making the entry, and their electronic signature must be included.
Poor documentation is the leading cause for malpractice lawsuits that can be very distressing for physicians and other clinicians. If the medical record is accurate in all respects, giving a clear idea of the patient’s health issues, evaluation and treatment decisions, it makes medical chart reviews for medical and legal purposes easy and uncomplicated. Accurate medical records also ensure that care providers are protected against malpractice litigation in case some adverse patient event occurs.