Remember the Basics of Good Documentation
December 1, 2022 2 minutes read
Proper documentation requires adhering to the basic goals of fully and accurately recording the patient encounter, says Richard F. Cahill, JD, vice president and associate general counsel with The Doctors Company, a malpractice insurer based in Napa, CA.
Cahill offers these pointers:
- Depending on the circumstances, chart notes should include a brief social narrative of relevant historical data, an explanation of the reason for the encounter, subjective complaints and observations reported by the patient, objective findings on physical examination by the clinicians, a diagnosis, treatment plan, and follow-up instructions for post-discharge care.
- Written directives provided at the end of the visit should be placed directly in the record to prevent future miscommunication or inaccurate interpretations of provider expectations. The note should be concise, professional, apropos, and impartial in both tone and description.
- Practitioners should be mindful of the many individuals who may later access the chart, including colleagues and other healthcare providers, regulatory and governmental oversight agencies such as professional licensing boards, state attorneys general, the National Practitioner Data Bank, and administrative law judges. The chart also may be seen by the Office for Civil Rights, hospital peer review and credentialing committees, CMS, and private third-party payors. The content of a medical entry may subject the author to deposition or trial testimony.
- Medical record notes must be made during or immediately after the event to ensure accuracy and reliability. Such documentation is considered inherently dependable and usually is admissible into evidence independently as the single most definitive statement of veracity and validity of an event.
- Offensive or inappropriate comments made by patients during a visit should be recorded verbatim using quotation marks to capture what the individual said.
- With expanded patient access through Open Notes, practitioners should pay greater attention to the content of chart entries, including word selection and tone as well as consider cultural sensitivity and diversity. References to an individual’s overall appearance and hygiene, especially if the comments do not directly relate to healthcare concerns, may unintentionally cause offense, which can inadvertently undermine the rapport critical to a strong professional relationship, promote friction, and increase the risk of adverse social media postings.
“Physicians should be cautioned that written materials contained in electronic or paper health records not uncommonly carry far-reaching implications and unintended consequences that are often not fully appreciated in the original context of the isolated patient visit,” Cahill says. “Pausing a moment before signing an entry may be a prudent approach.”
Proper documentation requires adhering to the basic goals of fully and accurately recording the patient encounter. Depending on the circumstances, chart notes should include a brief social narrative of relevant historical data, an explanation of the reason for the encounter, subjective complaints and observations reported by the patient, objective findings on physical examination by the clinicians, a diagnosis, treatment plan, and follow-up instructions for post-discharge care.
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