EXECUTIVE SUMMARY
Optimize documentation for patient safety and risk management. Avoid common mistakes and shortfalls.
- Overuse of cut and paste electronic health record features can affect documentation quality.
- Billing requirements should be considered in documentation.
- Artificial intelligence is becoming more common for improving documentation.
By Greg Freeman
Documentation is fundamental to both patient safety and risk management, but quality documentation relies on adhering to best practices and avoiding some of the most common mistakes.
The key factors to documentation success are redundancy and simplicity, says Robert Andrews, JD, CEO of Health Transformation Alliance in Scottsdale, AZ, which oversees the strategic direction of more than 50 major corporations to fix the U.S. healthcare system. Andrews served as a member of the United States House of Representatives for nearly 24 years.
“Several eyes ought to be on a document before it’s completed, and you try to make the process of entering the content of the document as simple as possible,” he says. “Typically, the people who do the documentation, if they’re clinical people, are really busy and under a lot of pressure, or they are administrative people who are overwhelmed with a lot of work to do. The risk here is you get people who are either distracted, overwhelmed, or otherwise busy.”
Andrews sees potential in the use of artificial intelligence (AI) to improve documentation. An AI system might be employed to listen in on a patient interaction or surgical procedure, with the permission of everyone involved, and immediately document the encounter in real time. That document can be augmented by additional input by clinicians. That technology holds promise for improving both the accuracy and efficiency of clinical documentation, he says.
“I think all health systems, one way or another, will be using AI as the dominant document creator very soon,” Andrews says. “The tricky question will become finding the blend as to where a smart human has to be more engaged or less engaged in that document creation. I think over time it will be figured out.”
Often, a provider is so rushed to get their charting complete they are looking for quick and easy ways to get it done, says Amanda B. Hill, JD, with the Hill Health Law Group in Bee Cave, TX. One of those is just cutting and pasting from other notes, which is called ‘cloning,’” she notes.
“This can often result in errors being carried forward in the record, and the authenticity of the entire record is questioned. An auditor or lawyer will think, ‘Hmmm, if you didn’t really observe this because it’s clear you cut and pasted, what else is real?’” Hill says. “It challenges the premise that the documentation is an accurate representation of what happened in the record.”
Also, doctors sometimes feel they need to insert personal issues in the record to protect themselves, such as when a patient was combative or if they are terminated from the practice, Hill says. Medical records really should be focused mostly on the clinical issues, not interpersonal issues, she says.
Clinicians sometimes make the mistake of thinking they only have to enter progress notes and someone else handles billing necessities, Hill says. But documentation can require certain things in order to get paid. Failing to include that information can lead to fraud charges, Hill notes.
“I had a therapist client once, for example, whose documentation was fine from a medical-legal perspective. But she didn’t understand she had to document the start and stop times in her notes,” Hill says. “And because she didn’t, it was considered a false claim and there was a huge audit, and they owed a lot of money back to Medicaid. So, part of the question is do you know how to document to get paid?”
Avoid Common Pitfalls
Poor documentation can lead to an assumption of substandard care, further underlining the need for physicians and practice managers to understand these common documentation pitfalls and devise strategies to circumvent them, says Marlene Icenhower, JD, CPHRM, senior risk management specialist at Coverys, a malpractice insurer based in Boston. She notes these most common pitfalls of documentation and best practices to avoid them:
- Ignoring the basic principles of documentation, which include legibility, accuracy, objectivity, and timelines. Adverse events should be documented objectively without admitting error, blaming others, altering records, or including inflammatory comments about patients or providers.
- Neglecting to document negative findings. These findings often provide a comprehensive view of the patient’s condition and guide treatment decisions. Healthcare professionals should always document what is present and what is absent.
- Inadequate diagnostic documentation. Documenting the complete thought process, the considered differential diagnoses, and the reasons for the chosen treatment can guide future care and provide valuable defense in a malpractice case.
- Misuse of electronic health record (EHR) features. EHRs offer time-saving templates and drop-down options, but misuse can lead to note “cloning” or incorrect documentation. It should be standard practice for clinicians to perform audits and double-check EHR entries.
- Improper documentation of informed consent or refusal. A thorough informed consent discussion should encompass an explanation of the proposed procedure or treatment, its benefits, risks, and alternatives. This discussion should be thoroughly documented and reflect the patient’s understanding and voluntary agreement.
- Poor follow-up on test results. A key contributor to diagnostic error is poorly managed test results. The implementation of a robust, dependable system for test result reviews and prompt patient communication can serve as a safety net, catching critical information that otherwise could slip through the cracks. Documentation should reflect these follow-up actions to ensure transparency and accountability in patient care.
Incomplete documentation can sabotage even the best medical practice, warns Thierry Hufnagel, a LASIK and cataract surgeon and board-certified ophthalmologist with Stahl Eyecare Experts in New York City.
“I cannot stress enough the importance of complete and accurate documentation when it comes to your healthcare practice. In my practice, I always stress capturing every detail of patient interactions. This goes past noting down the diagnosis and treatment plan; it includes recording patients’ questions, their concerns, and any advice we give them,” he says. “Why is this so important? It helps keep a clear record of the care provided and proves important if there are ever questions about the treatment outcomes.”
Relying too heavily on templates or putting efficiency above detail can compromise the quality of these records, Hufnagel says. Although templates are useful for not missing out on important information, they usually miss the nuances of individual patient cases, he says.
“Issues like not updating a patient’s medical history or their latest medications can lead to working with outdated facts, which is a no-go,” he says. “Also, using complicated medical complex language or unclear terms might leave others baffled when they review these notes.”
To address these challenges, Hufnagel meticulously reviews and adjusts the documentation for each patient to make sure it reflects their specific health conditions accurately.
“I also inspire my team to double-check for care and completeness in all entries. We cannot let minor oversights turn into major problems. Regular training sessions on documentation practices are a must in my team, where we focus on the importance of clarity, thoroughness, and care,” he says. “By getting documentation right, not only do we shield ourselves from potential legal troubles, but we also guarantee that our patients receive the best care they deserve.”
Incomplete documentation can lead to non-compliance with safety regulations, says Alex Stinard, MD, chief clinical AI officer with Augmedix, a company in San Francisco that uses AI to provide documentation and other healthcare data services. If key details are missing, it is hard to prove that necessary protocols were followed, which can cause problems during audits, he says.
Inadequate documentation also makes it difficult to track key performance indicators (KPIs). But if the documentation process is too time-consuming, it can take away from the time clinicians spend with patients, which is crucial for ensuring positive experiences and keeping patient care the top priority, Stinard says.
If AI is being used for medical documentation, maintaining human oversight and having a human in the loop is critical, he says.
“While AI is a valuable tool for automating documentation, it is not meant to replace the human element but to augment it by enhancing efficiency, reducing manual errors, and freeing up valuable time for clinicians to focus on patient care and decision-making,” Stinard says. “The accuracy required in our industry demands that clinicians remain involved to ensure that records meet the highest standards of care.”
The rapid adoption of ambient AI in healthcare underscores the critical role it is playing in advancing patient care and boosting operational efficiency, says Andreas Corti, CEO and co-founder of Corti, a company in Miami that provides AI documentation services for healthcare. However, not all AI is created equal, he says.
AI in healthcare should operate in real-time, enhancing interactions rather than simply recording them, Corti says. Effective documentation is achieved when AI actively engages with healthcare providers, offering nudges and prompts during live patient interactions to ensure optimal outcomes, he says. AI technologies in healthcare are advancing beyond simple note-taking to quality assurance, journals, codes, nudges, prompts, and documenting every patient interaction, he says.
“To fully harness the power of AI for documentation, the AI has to be trustworthy and lightning fast as well as seamlessly integrated into existing workflows. Trustworthy AI is built on a foundation of healthcare-specific data, ensuring best-in-class accuracy with minimal hallucinations,” he says “In today’s rapidly evolving regulatory landscape, AI that is finely tuned to healthcare’s unique demands will also be best positioned to navigate the complex intersection of healthcare, cybersecurity, and AI compliance. Furthermore, to really trust AI, providers of these tools have to take seriously the responsibility of interpreting their outputs.”
Sources
- Robert Andrews, JD, CEO, Health Transformation Alliance, Scottsdale, AZ.
- Andreas Corti, CEO and Co-Founder, Corti, Miami.
- Amanda B. Hill, JD, Hill Health Law Group, Bee Cave, TX. Telephone: (512) 329-2620. Email: [email protected].
- Thierry Hufnagel, Stahl Eyecare Experts, New York City. Telephone: (212) 689-7676.
- Marlene Icenhower, JD, CPHRM, Senior Risk Management Specialist, Coverys, Boston. Telephone: (800) 225-6168.
- Alex Stinard, MD, Chief Clinical AI Officer, Augmedix, San Francisco. Telephone: (888) 669-4885.
Documentation is fundamental to both patient safety and risk management, but quality documentation relies on adhering to best practices and avoiding some of the most common mistakes.
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