Page 9 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

PART ONE

Introduction

It is well-known that a complete and accurate medical
record will help foster quality and continuity of care. Most

importantly, it is the footprint that guides the course of the
patient’s medical care and provides needed information to

subsequent healthcare providers. What might not be as well-
known is that an incomplete or inaccurate medical record

can be a factor in causing patient harm. Although the primary
purpose of documentation is to facilitate good communication

among providers and continuity of care, when there are poor
outcomes, documentation often becomes the main focus

of litigation. Therefore, it is no surprise that the quality of
physician documentation not only spells the difference between

a defensible malpractice case and an indefensible one, but
also often determines whether the suit gets filed in the first

place. That’s because a malpractice case typically begins
with a plaintiff attorney’s review of the medical record. If the

attorney finds thorough documentation of medical care falling
within acceptable standards, there is very little chance that the

investigation will go any further.

Regardless of the method of documentation, be it paper
charting, dictating to a scribe or transcriptionist, or documenting

directly into an electronic health record (EHR), care should be
taken to ensure the medical record reflects the care provided to

the specific patient situation. Clinical documentation requires
the healthcare provider to accurately and objectively record the

observations, impressions, plans, and other pertinent data such
as a patient’s history, physical findings, and medical reasoning

leading to the chosen treatment plan.

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