Page 10 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Regardless of the method of documentation, be it paper charting,

dictating to a scribe or transcriptionist or directly into an electronic

health record, 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.

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.

As shown in the following graph, an analysis of SVMIC’s claims

data continues to reveal that documentation issues are a leading

contributor to many medical errors.

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