Charting Practices to Protect Against Malpractice

Abstract and Introduction

Abstract

Introduction: Medical documentation issues play a role in 10–20% of medical malpractice lawsuits. Inaccurate, incomplete, or generic records undermine a physician's defense and make a plaintiff's lawyer more likely to take on a case. Despite the frequency of documentation errors in malpractice suits, physicians receive very little education or feedback on their documentation. Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians' documentation and minimize their liability risks.

Methods: We used Thomson Reuters Westlaw legal database to identify malpractice cases related to documentation. Common issues related to documentation and themes in the cases were identified and highlighted.

Results: We classified cases into the following categories: incomplete documentation; inaccurate text; transcription errors; judgmental language; and alteration of documentation. By evaluating real cases, physicians can better understand common errors of other practitioners and avoid these in their own practice.

Conclusion: Emergency physicians can reduce their liability risks by relying less on forms and templates and making a habit of documenting discussions with the patients, recording others' involvement in patient care (chaperones, consultants, trainees, etc.), addressing others' notes (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated information, avoiding judgmental language, and refraining from altering patient charts.

Introduction

More than 75% of emergency physicians will be named in a malpractice lawsuit at least once throughout their careers.^[1] Documentation issues are thought to play a role in up to 20% of these lawsuits.^[2] Previous studies of malpractice claims involving documentation indicate that these cases most commonly revolve around missing documentation (70%), inaccurate content (22%), or poor mechanics (18%).^[3] Poor mechanics includes errors in transcribed order, illegible entries, and delays in documentation.^[3] Physicians often focus on documentation as a means of communicating with other physicians and billing for their services, but it is also crucial to communicate with the patient and provide a legal record of the care provided. Often, malpractice lawyers decide whether to pursue litigation cases based solely on the quality of documentation. In malpractice cases, inaccurate, incomplete, or careless records undermine a physician's defense and make a plaintiff's lawyer more likely to take on a case.^[2]

Despite the frequency of documentation issues in malpractice suits, physicians receive very little education on this topic through training and very little feedback on their documentation once in practice. The Accreditation Council for Graduate Medical Education does not specifically address or require medicolegal education, lending to varying levels of exposure and training on these topics. When surveyed, residents and physicians across multiple specialties reported receiving no medicolegal training at all, let alone training that is specific to documentation, and rated their knowledge as poor.^[4–6] Emergency physicians are particularly at high risk of documentation malpractice liability due to the large number of high-risk patients and fast-paced environment. The objective of this case series was to evaluate malpractice cases related to documentation errors and practices to help improve physicians' documentation and minimize their liability risks. By evaluating real cases, physicians can better understand practices and common errors of other practitioners and avoid these errors in their own practice.