Clinical documentation is integral to effective medical practice, ensuring not only patient safety but also acting as a critical defense in malpractice cases. The Candello 2024 Benchmarking Report, “For the Record: The Effect of Documentation on Defensibility and Patient Safety,” breaks down how various documentation factors can contribute to medical malpractice cases.
The report leveraged the Candello database, which contains almost half a million coded cases, representing almost one-third of medical professional liability (MPL) claims and lawsuits in the United States. Out of more than 65,000 cases closed between 2014-2023, 20% had documentation issues.
The analysis indicates that certain documentation errors can double, triple, or even quadruple the odds that a case will close with an indemnity payment compared to cases without that error.
Aram Zadow, a senior claims representative for CRICO, the medical malpractice insurer for the Harvard medical community, gives his perspective on how the seven documentation factors can impact the defense of care: “The more detailed your note, the better your defense.”
This article will review the seven different types of clinical documentation errors and what you can do to avoid them.
Error #1: Insufficient Documentation of Clinical Findings
Insufficient documentation of clinical findings is present in more than 30% of documentation cases. This factor refers to clinical documentation that lacks crucial information regarding a patient's medical history.
Zadow deals with this error often. He explained that doctors may exclude details due to how rote certain practices and procedures have become to them. To rectify this error, doctors should include as many details as possible in their clinical documentation.
Error #2: Inconsistent Documentation
Inconsistencies in the medical record can result from poor communication or stem from multiple notes from various providers. For example, a nurse or resident may record information that an attending physician does not due to patient rounds and detail discrepancies. Documentation templates can also lead to inconsistent documentation, which can include pre-existing text such as the review of systems in a note template. That pre-existing text, if not appropriately deleted, may conflict with the part of the note that the clinician actively edited.
To avoid inconsistencies in documentation, it is crucial to ensure that the record accurately reflects the patient's current health status by reviewing notes and entries.
Error #3: Insufficient Documentation of Clinical Rationale
More than 10% of documentation cases include instances where the clinical reasoning is not noted in the record.
The Candello report suggests that documenting abnormal test results, discussions, and follow-up recommendations can close the loop in communication, helping to avoid adverse events and MPL cases.
Another compelling reason for clinicians to detail their clinical rationale is that it can help them in the event of an MPL claim. If a case is filed related to a clinical decision that, in hindsight, appears questionable, and if there is a thoughtful clinical rationale specified in the chart, then that case may still be defensible as having met the standard of care.
Error #4: Informed Consent
Issues surrounding the documentation of informed consent were seen in more than 10% of documentation cases, and the factor almost doubled the odds of indemnity payment.
Despite good documentation habits and the presence of a signed consent form, cases may still occur. In short, the patient still has the right to sue. Sound documentation of informed consent can be achieved by asking patients to repeat what they understood and note their responses.
Error #5: Illegible Documentation
Illegible documentation accounted for the second fewest percent of cases, with less than 5% of cases involving this factor. As technology has impacted the medical record, illegible documentation has receded as an issue.
Adam Schaffer, MD, a senior clinical analytics specialist of Patient Safety at CRICO, explained why illegible documentation has had a history of a high odds ratio for a case closing with payment. Schaffer attributed the high odds ratio to the fact that illegibility represents poor documentation habits more broadly.
“Illegible documentation is likely to be a proxy for multiple poor documentation practices,” Schaffer explained.
“The same doctor who writes a few illegible sentences in the chart after a patient visit is also unlikely to do a good job documenting their clinical rationale or, in a detailed way, include the relevant clinical findings,” Schaffer suggested.
Error #6: Altered Documentation
Of course, intentional alteration of the documentation after an adverse event is unethical and should never be done. In the event of good-faith entry of a delayed note or editing of a note, this should be indicated. For example, label these notes as “late entries” to avoid issues with patient care and legal defense. Electronic health record (EHR) systems contain audit trails that include the date/time the note was edited, as well as the original version of the note, prior to the edits.
Documenting the date, time, and details of a late entry is important. “Without clear documentation of timed entries, plaintiffs can exploit that gap,” Zadow explained. Even when entered in good faith, a delay in entering a note can detract from its credibility in an MPL case. As much as possible, documentation should be performed contemporaneously with the provision of the clinical care.
Error #7: AI and Technologies
As technology evolves, the nature of documentation errors is likely to shift. While AI and EHRs have the potential to streamline documentation and reduce some types of errors, they also introduce new risks.
The report lists a plethora of documentation risks in the digital age, including:
- Copy-and-paste issues
- Scribes
- Texting
- Templates
- Patient portals
- AI and the future of documentation
Common issues such as copy-and-paste errors, over-reliance on templates, and the misuse of predictive text can compromise the accuracy of patient records. Additionally, the use of scribes and texting for medical instructions can lead to inconsistencies and miscommunications.
To mitigate these risks, it is essential for healthcare providers to receive ongoing training in the effective use of these technologies. This includes understanding the limitations and potential pitfalls of AI and EHRs, as well as adopting best practices for maintaining accurate and detailed documentation. Especially as AI is being rolled out more broadly in healthcare, clinicians must thoroughly review and as needed, edit any content generated by AI. By fostering a culture of meticulous record-keeping and continuous education, the healthcare industry can harness the benefits of modern technology while maintaining high standards of patient care and legal compliance.
While technological advancements offer significant benefits for medical documentation, they also require careful implementation and oversight to ensure they do not introduce new errors. By recognizing and addressing these challenges, health care providers can improve documentation practices and ultimately enhance patient safety.
Protect Yourself from MPL Claims
Candello’s 2024 Benchmarking Report outlines the varying documentation errors that can tip the scales in the courtroom. To better understand the errors, the report provides best practices to improve documentation habits and enhance patient safety efforts.