Page 12 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 Documenting information in multiple areas of the record with

discrepancies between locations (i.e, allergies,

immunizations, problem list)

 Lacking documentation of physician review of results of lab

or diagnostic studies

 Lacking documentation that patients are notified about the

results of lab or diagnostic studies

 Missing or inadequate informed consent documentation

 Late documentation or late completion of office notes

 Missing or inadequate documentation of discharge/follow-up

plans

 Missing or limited documentation of phone calls with

patients

 Missing documentation of phone calls/conversations with

other care providers (consultants, hospital nurses, home

health)

 Missing, illegible or “stamped” signatures

 Missing documentation of a patient’s nonadherence to the

treatment plan

There are many factors that contribute to poor documentation

including time pressures, unfamiliarity with EHR systems or

protocols, compliance concerns, and hybrid charting using a mix

of paper and EHR. Before delving into case studies that highlight a
particular documentation issue, let’s review tips from a medical

malpractice trial consultant about the importance of

documentation to a jury.

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