Documentation Errors That Can Place You and Your Practice at Risk in a Malpractice Lawsuit

In this article, I am going to highlight documentation errors that could reduce your reimbursements, hurt you in an insurance audit or, even worse, could cause you to lose a malpractice lawsuit. 

1. Failure to Document Phone Calls. 

Every clinical encounter you have with a patient should be documented in the patient file, even if it is a phone conversation with you or one of your staff members. It is important that staff not be allowed to give medical advice to patients over the phone or any other time. As a licensed professional you are responsible for any medical advice your staff may provide to a patient. If a patient is asking for medical advice over the phone, the call should be directed to the appropriately licensed provider, and the licensed professional should document the conversation and any advice provided to the patient. It is important to keep in mind that a patient’s phone call could be the last form of communication with your office before a lawsuit is filed.

2. Failure to Document a Patient’s Noncompliance.

A patient who is noncompliant with an important treatment plan can be frustrating for a doctor and staff, but he or she is also more likely to file a malpractice suit than a compliant patient. It is important to document a patient’s missed appointments, failure to follow a treatment plan, or refusal to stop activities. It is also important to document when a patient drops out of care. In addition, providers should document when a patient refuses to see a referred practitioner or take ordered medical tests. Document all communications, whether verbal or in writing, used to convey a patient’s noncompliance. These records can help protect you in a lawsuit.

3. Failure to Document Homecare Instructions.

Document any instructions were given to a patient regarding activities or restrictions outside of your office. This includes instructions to ice, as well as for instructions on altering Activities of Daily Living and/or exercises. It is also important to follow up with the patient to determine if the patient is following the instruction as given.

4. Failure to Document Informed Consent.

Before treating a patient, it is important that the patient is provided with sufficient information to make an educated decision about his or her care. A doctor can use an informed consent form that the patient signs or document a discussion that took place about the patient’s care and that the patient consented to care. ICS Members have can access an example of an Informed Consent form at www.ilchiro.org/.

5. Failure to Obtain Consent to Treat a Minor.

When treating a minor, a doctor must obtain consent to treat the minor from the adult who has custodial supervision of the minor. Keep in mind this person may not always be the minor’s parents but another family member. Again, ICS Members have can access a full article that discusses Consent to Treat a Minor at www.ilchiro.org/.

6. Failure to Document a Follow-up Date or a Discharge Date.

The date a patient is expected to return for follow-up treatment should be documented in the patient’s file. If a patient is instructed to return as needed, this should also be documented in the patient’s file. When discharging a patient, you should document the date of discharge, the patient’s condition upon discharge, and any follow-up care instructions. Documenting these dates and instructions can help a doctor fight abandonment allegations. 

7. Failure to Document Patient Education.

Document any form of patient education used to educate a patient about his/her condition. This includes any videos, pamphlets and/or report of findings conversations. This shows that the patient was educated about his/her condition. 

8. Illegible, Altered and/or Unsigned Notes.

All notes need to be legible, dated and signed. Notes should be written within 24 hours. All abbreviations should be standard. DO NOT alter notes after signing. When a documentation mistake occurs, or information is omitted from a patient’s records, it is important to make an addendum to correct the mistake. The proper way to make an addendum is to leave the original note as is and add a new entry that explains the error or provides omitted information. The new entry should be dated when it is actually written, not back-dated to the original note. The original note should not be altered at any time after your signature is applied. The fastest way to damage credibility in a malpractice suit is to change your documentation. 

9. Carbon Copy Records.

Records that do not change regularly indicate that a patient is not improving. If a patient is not improving, then why is he or she still under active care? Duplicated documentation on multiple visits can be a problem with electronic health records (EHR). If your documentation is not changing because the patient is not improving, then it is probably time to refer the patient to another provider or for another course of treatment. Many malpractice cases result from a patient being under prolonged care and failing to improve when they had some other condition such as cancer or an aneurysm. 

10. Failure to Provide Clinical Rationale and Written Reports for Diagnostic Tests.

When diagnostic tests are performed or ordered, the rationale for the test must be documented in the patient’s file. A written report of the test results must be included in the patient’s file, and the physician should document how the patient’s care is affected by the test results and how the patient was notified of the results.

11. Using Subjective Language in a Patient’s File.

It is important to keep your language in a patient’s file objective. Use words that clearly state the patient’s condition or the care provided. The use of subjective language can be misinterpreted. For example, if a patient is not performing his home exercises, do not state that the patient is “lazy.” It is clearer to state that the patient is noncompliant in following home exercise instructions. 

12. Making a Patient’s Condition Sound More Severe.

Overstating or understating the severity of a patient’s condition (making it better or worse) to justify treatment or improvement can come back to haunt you in a lawsuit. It is also important to never guarantee results.

13. Failure to List a Patient’s Contraindications.

Place all contraindications to therapies or treatments in the patient’s file where it can be seen. The wrong manipulation or therapy could have negative effects on a patient.

14. Failure to Record How the Patient Responded to Care.

Record how a patient responded to care for each and every visit. This protects you in a malpractice case. For example, ask the patient how he or she feels after an adjustment, therapy and/or exercise. This may help protect you if a patient files suit at a later date stating that you hurt them.

Proper documentation can improve a patient’s condition, assist you in an audit or protect you during practice. The information in this article can assist you in improving your documentation. The information in this article is not offered as legal advice. Please consult your attorney regarding legal issues.