Published April 20, 2022
This Expert Consult provides a general overview of some risk and legal issues associated with medical record documentation. It is not a substitute for the guidance of your attending or the counsel of your institution’s risk management, legal, or other professional staff. Law and practice may vary greatly outside the United States.
Notes are often the last thing standing between you and (finally) going home. In one large-scale survey of internal medicine residents, two-thirds reported spending more than 4 hours per day on medical record documentation and clerical duties; only one-third spent comparable time on direct patient care (see also Chen et al. and Wenger et al.). Although time-consuming, documentation is essential to delivering excellent patient care. The ultimate goal of documentation is to record the patient’s condition and communicate your thoughts and actions to other health care providers. Other important purposes and uses for documentation include reimbursement, quality measurement, and litigation, but the communicative goal should remain paramount.
Despite its importance to the delivery of care (both clinically and operationally) and the large amount of time and effort it requires, documentation quality is often less than ideal. Moreover, many residents receive little training, supervision, or feedback on their documentation practices. With this educational gap in mind, we highlight some problem areas and present principles for more precise, relevant, and useful documentation. These principles will not only improve patient care, but may also help protect you and your institution should your care ever be called into question.
Honing a patient’s “story” into an articulate written product is no easy task, and in many ways, the “copy/paste” functionality of electronic health records has not made it any easier. So-called “note bloat” occurs when extraneous information “bloats” the record, making it difficult for others to find new or clinically relevant information (see Kuhn et al. and ECRI Institute Special Report).
Before you paste, consider whether the information is truly useful to the next provider. For example, rather than pasting the day’s lab results into your progress note, specify that you reviewed the results and note only the values relevant to the plan of care (e.g., hemoglobin decreased from 9 mg/dL on 4/13/17 to 7mg/dL on 4/14/17, representing likely acute blood loss anemia). Contrary to the belief of some residents, reimbursement does not require documentation of all results. Although it is sometimes more convenient to include all the data in your progress note, a more effective communication strategy is to paste only the values you find clinically relevant.
Beyond contributing to “note bloat,” copy/paste can also contribute to incorrect and inconsistent information as described in the following examples:
Introducing incorrect information
Dr. X copies recommendations from patient A’s chart to patient B’s chart, since they both have the same infection. While revising, Dr. X accidentally leaves in a reference to patient A’s medication allergy, thereby introducing misinformation in patient B’s chart.
Propagating incorrect information
Dr. X notes a rash on the patient’s right leg, but mistakenly documents a rash on the left leg. Dr. Y copies this error into her note later that day. Although Dr. X corrects his note the following day, the error has already been propagated. The following week, Dr. Z copies Dr. Y’s note, further distributing the erroneous information.
Promoting internal inconsistencies
On day 1, Dr. X’s note reflects the patient has a fever. On day 2, Dr. Y copies Dr. X’s note, revising it to reflect several changes, including that the patient is now afebrile. However, Dr. Y accidentally leaves in the sentence stating the patient has a fever. Dr. Y’s day 2 note therefore states both that the patient has a fever and is afebrile.
Despite these pitfalls, the usefulness of copy/paste is widely acknowledged and most institutions allow it with certain limitations. You can guard against inaccuracies, inconsistencies, and “note bloat” by not repeating unnecessary information and carefully editing what you paste: Think of the function less as “copy/paste” and more like “copy/edit.” Also, try to put yourself in the shoes of a subsequent provider and ask yourself, “Would I want to be on the receiving end of this communication?” Finally, since the information you write will also likely end up being copied and pasted at some point, use your name instead of “I” and the actual date instead of “today,” since both will lose their meaning if pasted into another provider’s note at a later time.
You will not have enough time to document as articulately as you would like in every situation. Therefore, be cognizant that certain scenarios should trigger closer attention to detail, as described below:
Changes to plan of care
Understanding the reasoning behind a change to plan of care should not require a co-treater or subsequent treater to “read between the lines.” Take care to fully explain your thought process. Not doing so leaves room for someone else to put forth their own interpretation of what you were thinking.
Ideally, code status discussion should include:
· patient goals/values
· options and/or expected outcomes
All three of these factors are necessary to paint a complete picture of the patient’s understanding and wishes and should be documented, but often are not.
Conversations with a patient (or their family/friends) are sometimes the basis for misunderstandings that can turn into a complaint or claim. A helpful habit is to record at least the general theme of salient conversations, since you are unlikely to remember them later.
A good discharge summary necessarily requires analysis and synthesis on your part. Therefore, pasting together a patchwork of previous notes will rarely result in a product useful to a subsequent provider.
Take care to ensure your discharge summaries are clear about medication details and follow-up plans (often deficient in resident-authored discharge summaries).
As noted above, conversations are important — especially those related to discharge — because it is often a stressful time for patients. Verbally emphasize and repeat the most important information to patients (e.g., time frame for follow-up, when to go to the emergency department), and note that you did so.
Patient harm-related events
No universally-accepted set of definitions currently exist to describe events that result in (expected or unexpected) harm to a patient (e.g., complication, medical error, safety event).
When harm does occur, consult with your attending on how it should be documented; generally, be factual and avoid blame. It is not your job to determine who or what contributed to or caused a particular event. Institutional policy plays a big role in how harm-related events are handled and documented.
Many electronic health record (EHR) systems have the capability to go well beyond simple audit reports showing, for example, whether any staff inappropriately accessed a celebrity patient’s record. EHRs can also show deleted information, what time a radiology report was opened (and how long it stayed open), and the number of times labs were reviewed. This capability should not necessarily change the way that you use the EHR, but it is good to keep in mind that these data do exist and are increasingly being requested by attorneys and regulatory agencies when care is called into question.
In a challenging situation, you may understandably be tempted to document, “Jane Smith from risk [or legal, or some other department] said to do X.” In most cases, this sort of documentation does not pose a problem, but some institutions actually advise against it. In some states, advice from legal or risk management advisors is subject to privilege (i.e., is not “discoverable” in a lawsuit or investigation); documenting the advice given may surrender that privilege. Likewise, in some states, mentioning in your note that you completed a patient safety report can make that patient safety report discoverable, when it would otherwise be protected. The bottom line: Find out what your institution considers best practice when it comes to documenting non-clinical consults.
Including documentation in medical education may soon become more prevalent: In 2015, the American Academy of Physicians called for improvement in this area. As training programs try to catch up, residents are in a great position to advocate for improvement at their own institutions. See, for example, this resident-driven project that educated on the legal implications of documentation by presenting a mock deposition by legal counsel. Whether you seek improvements at your institution or simply think before you “paste,” honing good documentation practices during residency is a worthwhile endeavor — from a clinical, operational, risk, and legal perspective.