Good documentation in the patient’s medical record can be a primary defense against allegations of malpractice. A well-documented medical record may actually prevent a lawsuit from being filed. On the other hand, poor documentation or alterations in the medical record can render an otherwise defensible case indefensible. Medical record documentation should accurately reflect the care and treatment provided to a patient and that the standard of care was rendered. Good documentation is also crucial in the coordination and communication of patient care with other healthcare providers and to justify billing. Documentation should be legible, accurate, clinically relevant, chronological, objective, clear, complete and specific.

For a comprehensive documentation guide for paper and electronic medical records, go to PICA’s website.

There are valid instances when correction of an erroneous entry, late entries of necessary clinical information, addendums to prior entries or amendments to the medical record need to occur. In these instances, appropriate steps should be taken to clearly document who made the entry, when the entry was made and why the entry was made.

Changes to the medical record should not be made after the record has been copied and released, such as to an attorney. Any changes to a record after a copy has been released results in two versions of the record. In the event of a lawsuit, suspicions of record alteration will be raised. Any hint of record tampering may completely shatter the
credibility of the record and of the defendant and may lead to a plaintiff’s verdict, regardless of the medical facts or merit of the case.

Never alter a medical record. If it is determined that medical records have been changed without justification, the credibility of the entire record may be destroyed. Not only will record alteration severely damage the chances of prevailing in a lawsuit, but it may put professional liability coverage for the incident at risk.

Please refer to PICA’s "Documentation Essentials: Using Documentation to Support and Defend Your Good Care" available to policyholders on PICA’s website for detailed information regarding error correction, late entries, addendums and amendments to the medical record.

As soon as possible after discovering an unexpected outcome, document the event in the patient’s medical record. Documentation of unexpected outcomes should be factual. The documentation should not contain subjective comments, blame or speculation about what happened.

For example, documentation regarding a patient who developed a hallux varus following a bunionectomy should include the physical findings, results of X-rays, the diagnosis and plan for future treatment. Documentation should not include your theory of the reason for development of the hallux varus.

After you have communicated the facts to the patient and/or family, document the information discussed; the date, time and place of the discussion; the names of those present; and your plans for subsequent treatment.

For example, “2/5/2015 – 3:00 p.m. Met with patient and his wife in my office and explained to them that the patient developed a hallux varus after his bunionectomy. I provided them with education regarding hallux varus and explained that, as we discussed pre-op, this is a complication of bunionectomy. I discussed treatment options including conservative treatment and surgery and the risks and benefits of each. The patient would like to try conservative treatment prior to considering surgery.”