Medical Record Documentation for Patient Safety and ...

1 Medical Record Documentation for Patient Safety and Physician Defensibility A Handbook for Physicians and Medical Office Staff January 2008. Owned by the policyholders we protect. Authors and Editors: Medical Record Documentation for Patient Safety and Physician Defensibility is a publication David Karp, , , Former Loss Prevention Manager, received a Bachelor of Arts degree from Columbia University and a Master of Arts of the MIEC Loss Prevention degree from San Francisco State College. He was involved in Medical Department. The authors malpractice claims and loss prevention activities on behalf of physicians have conducted hundreds of between 1966 and 2000.

2 Medical practice surveys and Judith M. Huerta, , , Loss Prevention Manager, received a Bachelor have reviewed thousands of of Science degree from Chadron State College, Chadron, Nebraska and a Medical records maintained Master of Arts degree from John F. Kennedy University, Orinda, California. by physicians in all Medical She has been involved in Medical malpractice claims and loss prevention specialties. Each of the authors activities on behalf of physicians since 1985. has extensive experience Claudia A. Dobbs, , , Loss Prevention Assistant Manager, received in Medical malpractice a Bachelor of Arts degree and a Master of Arts degree from California claims management and State University at Hayward.

3 She is a certified paralegal and was employed loss prevention activities by a malpractice defense firm for ten years prior to joining MIEC's Loss on behalf of physicians and Prevention Department in 1992. other health professionals. Dorothy L. Dukes, , Senior Loss Prevention Representative, has Recommendations for extensive experience as a defense representative, claims reviewer, and defensible Medical records paralegal for Dalkon Shield Claimants Trust and served as a family mediator are based on the authors' for the Supreme Court in Richmond, Virginia.

4 Ms. Dukes was a department analyses of Medical records and supervisor for the American Arbitration Association in San Francisco, malpractice litigation files, and California, prior to joining MIEC's Loss Prevention Department in 2001. include Documentation advice Kathy Kenady, , Loss Prevention Representative, received a Bachelor from malpractice defense of Arts degree from the University of California at Santa Cruz. She assisted attorneys, claims experts and in the Government Relations division of the California Medical Association physicians whose involvement in Sacramento, California, and went on to advocate for physicians and their patients for four years as the Associate Director of the Alameda-Contra in peer review activities gives Costa Medical Association in Oakland, California.

5 She joined the Loss them a unique understanding Prevention Department in March 2005. of the importance of sound Medical Record Documentation . This publication was developed and updated under the direction of the No reproduction without Loss Prevention Committee of the MIEC Board of Governors. permission. Copyright 1998, 2003, 2008. Medical Insurance Exchange of California, Oakland, CA. Table of Contents Recommendations for Defensible Medical Records Organize charts .. 5. Avoid the use of sticky notes .. 5. Note the reasons for visit .. 5. Triage Template (Figure 1).

6 5. Chart allergies, current medications, names of other physicians .. 6. Consider a Problem List in group practice charts .. 6. Sign or initial all chart entries .. 7. Write legibly! .. 7. Dictated your 8. Consider an electronic Medical 8. Avoid untimely 8. Do not use a Dictated but not read stamp or note on transcription .. 9. Initial or sign questionnaires as evidence of your review .. 9. Fill in or void spaces on forms and transcription .. 9. Initial or sign lab, X-ray, consultants' reports as evidence of your 9. Lab, X-ray Report Review Template (Figure 4).

7 10. Avoid unexplained crossouts, writeovers or squeezed-in entries .. 10. Chart medication prescriptions and renewals 11. Use a Medication Control Record .. 11. Medication Control Record sample (Figure 6).. 11. Dispense drug education materials and document the 12. Document significant phone conversations with dates, names, and 13. Document referral notes unambiguously .. 13. Include sufficient details of exam findings in progress 13. On-call Physician's Report Form (Figure 7).. 14. Telephone Message Slip (Figure 8).. 15. Supplement narrative text with line drawings, diagrams and 15.

8 Document informed consent discussions 16. Document informed refusal 16. Document patients ' noncompliance in the progress Record .. 17. Chart evidence that Patient education information was 17. Document return visit advice in each progress 18. Document failed and canceled appointments in the progress 18. Did-not-keep-appointment (DNKA) Template (Figure 9) .. 18. Resolve Medical problems from previous visit in the chart .. 19. Write unambiguous return-to-work or school 19. Avoid unsubstantiated subjective remarks in the progress 19. Avoid criticism of other professionals in chart 19.

9 Use prenatal forms with adequate space for data; complete forms 20. Document prenatal risk 20. Frequently Asked Questions about Medical records .. 21. 1. Documentation Review Self-Assessment .. 31.. Nothing is more devastating to an innocent physician's defense against the allegations of Medical malpractice than an inaccurate, illegible or skimpy Record , except for a Record which has been changed after the fact, and therefore inevitably compromises the otherwise defensible case.. Brad Cohn, MD, Pediatrician Chairman, MIEC Board of Governors Oakland, California 2.

10 Medical Record Documentation for Patient Safety and Physician Defensibility A Handbook for Physicians and Medical Office Staff Few Medical -legal topics have generated as much discussion as the subject of Medical Record Documentation . Liability insurers, defense attorneys, and third party payers remind physicians and other health professionals that the Safety of patients , the outcome of litigation and the promptness of reimbursement depend on the adequacy, legibility, completeness, timeliness and accuracy of Medical records. Many malpractice claims result in a victory for the plaintiff because of the poor quality of Medical records, even in cases in which appropriate Medical care was provided.