Page 10 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

An accurate medical record can be the first line of defense in

the event that the care is challenged. Conversely, an inaccurate
record can lead to errors in the decision-making process,

resulting in an ineffective treatment plan that will be difficult to
defend in a court of law. Juries expect that the documentation

not only reflects the care received but is also a reflection of
the physician providing the care. It is very difficult to explain

conflicting entries to a jury. Improving documentation is a goal
that is continually being emphasized and for good reason.

You are encouraged to routinely assess the quality of

documentation by periodically reviewing a random sample of
medical records based on your practice’s specific policies and

procedures. For example, you may want to define acceptable
time frames and protocols for completing records, correcting

entries, authenticating entries or reports, and documenting late
entries.

Based on SVMIC claims involving non-hospital-based
physicians, which closed from 1/1/2014 to 12/31/2019,

documentation issues represented almost 30 percent of the risk
issues identified and warrant additional effort to mitigate the risk

of a medical malpractice claim.

Of the claims with documentation issues, the top three issues
are:

1. Inadequate/omitted documentation

2. Untimely documentation

3. Electronic Health Records

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