Page 31 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

The defense expert conceded that the primary care

physician’s documentation was below the standard of
care. The case was difficult to defend and a settlement

was reached.

Moving on to the second critical element when documenting for
defensibility: accuracy matters. Accuracy will not only be able

to support your care in the event it’s challenged, but it is also so
important for the other physicians who subsequently treat your

patients. In contrast, if the record is inaccurate, it may lead to
errors in decision-making and it makes it very difficult for your

defense attorney to explain those inaccurate conflicting entries
to a jury.

Timely documentation is critical in order to ensure an accurate
and complete record of the patient encounter. Office notes and

dictated procedure notes should be completed, reviewed and

signed within 24 to 48 hours. Late completion of notes puts
you and your colleagues at risk. Delay hinders accuracy, and
efforts to catch up often lead to incomplete documentation.

Any intervening adverse event prior to completion of notes

makes late documentation appear self-serving. One of the
‘Golden Rules’ of documentation is that the medical record be
prepared as contemporaneously with treatment as possible

to avoid confusion and to ensure accuracy. The defense of

malpractice lawsuits has taught us that juries often assume
that undocumented events never happened. The importance
of contemporaneously documenting care is particularly crucial

when documenting after-hours. Calls to a physician or other

care provider outside of normal office hours are often of a
serious nature. Without contemporaneous documentation,
the physician has to rely on memory to recall the advice or

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