Avoid the Common Pitfalls in Medical Documentation
April 1, 2025
By Greg Freeman
Medical professionals often work under time pressure that results in some of the common pitfalls in practitioner documentation, says Daniel Kent Cassavar, MD, medical director of The Doctors Company, an insurer in Napa, CA. Cassavar notes these common pitfalls to watch out for:
- Inconsistent or incomplete documentation: Contradictory information or missing details can weaken medical records.
- Delayed entries: Clinicians should ensure notes reflect real-time documentation, because entries made significantly after the event may be void of critical but forgotten information and lack credibility. To this end, organizations should prioritize workflows that make it easier for practitioners to complete their notes on the spot.
- Overuse of templates or copy-paste: When practitioners avoid over-relying on prefilled text in electronic health records (EHRs), they can prevent frustrating, wading-through-the-weeds experiences for themselves and their colleagues. Making critical information more readily available increases patient safety and mitigates medical professional liability.
- Unclear language: Practitioners should stick to standard abbreviations rather than using a personal shorthand.
- Judgmental language: Nonclinical language can appear biased or unprofessional, so clinicians should use care when composing subjective comments.
- Noncompliance with institutional guidelines.
Changes to records after a dispute arises can be interpreted as tampering — even if the clinician’s intentions were honest, Cassavar notes. Therefore, practitioners should beware of the temptation to make post hoc edits, because EHRs log all changes.
“Sparse or vague entries can make it harder for a defense team to justify clinical actions or prove adherence to the standard of care, so clinicians should use specific times, dates, and descriptions,” he says. “Personal comments about the patient can diminish the practitioner’s perceived trustworthiness, so clinicians should avoid defensiveness in documentation, especially in challenging cases. It helps if we focus on keeping clinical notes factual and neutral.”
Healthcare practices and institutions should strive to help clinicians strike a balance between leaning on provided tools, including assistive automation, and scrutinizing the results for accuracy, Cassavar says. For example, practitioners should accede to institutional requests to use systems safety tools like checklists or forms, as failure to do so can create gaps. At the same time, practitioners should avoid blind trust in automation, which can lead to overlooking inaccuracies in templated data, he says.
Healthcare professionals in certain specialties face additional challenges in preparing quality documentation, Cassavar says. These include:
- Emergency medicine: Emergency department practitioners are making rapid decisions in a high-distraction environment. Both of these factors increase the difficulty of capturing complete documentation. Practitioners are encouraged to focus on basics like clarity, chronological organization, and professional tone. Good documentation tells a clear story.
- Behavioral health: Sensitive topics are the mainstay of behavioral health documentation. To allay litigation risks, practitioners need to exercise skill and care in phrasing their clinical notes.
- Obstetrics/pediatrics: Statutes of limitations tend to be long with respect to care provided to minors. Practitioners in obstetrics and pediatrics need to document for clarity over the long term, creating records that will withstand scrutiny years, even decades, later.
- Surgical specialties: Vague operative notes or questionable informed consent documentation can heighten liability.
“Healthcare practices and organizations can mitigate liability risks through clinician training, emphasizing documentation fundamentals like accuracy, clarity, and timeliness,” Cassavar says. “They also should focus on checklists, implementing structured templates, and iterative cycles of audits, interventions, and documentation improvements.”
Source
- Daniel Kent Cassavar, MD, Medical Director, The Doctors Company, Napa, CA.
Medical professionals often work under time pressure that results in some of the common pitfalls in practitioner documentation.
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