Documentation Tips to Reduce Malpractice and Avoid Lawsuit Risk

Since 2010, medical documentation has become a central focus in healthcare discussions. The process of documenting patient visits is often tedious and requires a great deal of attention, but it remains essential for patient care, a physician's reputation, and the overall success of a medical practice.

Every year, juries review numerous malpractice cases, where the outcome often depends on the quality of the medical records. When documentation is deemed incomplete or poor, the chances of the case resulting in an indemnity payment rise by 76%. Moreover, 70% of patient claims related to diagnoses stem from issues arising due to improper documentation. This highlights the importance of accurate medical documentation. In this article we will delve into the strategies and tips on how to improve the quality of medical documentation and reduce the risk of malpractice suits in not-taking and clinical documents.  

Strategies to Improve the Quality of Medical Documentation 

Doctors usually handle documentation with the aim of communicating clearly with themselves. This becomes an issue when malpractice claims are filed, and plaintiff attorneys, arbitrators, or juries conduct reviews of the records that are often influenced by emotions like anger or sympathy, leading them to assume negligence due to missing or incomplete details unless proven otherwise.

Below are 6 strategies for physicians to improve the quality and effectiveness of their documentation efforts.

Accuracy

The most critical aspect of any medical record is its accuracy. Inaccurate notes can greatly increase the likelihood of a malpractice claim. While it’s essential to ensure accuracy when documenting a patient encounter, the process can be made easier with tools like a recording device or a transcriptionist.

Where inaccurate documentation can cause the most harm is during the medical coding process for insurance claims. Research shows that around one-third of patient visits are under-coded, a mistake that leads to significant financial losses for healthcare providers. In fact, billing errors across the healthcare industry cost more than $60 billion annually.

Many clinical documentation improvement (CDI) programs stress the importance of proper medical coding. By adhering to ICD-10 codes and using coding tip sheets, providers can reduce errors, minimize related costs, and lower the risk of malpractice lawsuits.

The World Health Organization and the ICD have already released ICD-11 in January 2022.

No Copy/Paste 

Using copy and paste techniques for EHR documentation might appear to be an efficient way to speed up the process, but it introduces significant risks to the quality of the records. When information is copied, important details can be missed, or incorrect data may be added unless the content is thoroughly reviewed before being included. Additionally, relying on external sources raises concerns about the authenticity and credibility of the information, especially if the original source cannot be verified.

In malpractice cases, juries that discovered a physician had used copy and paste methods were more likely to rule against the doctor. They viewed this as a clear indication that the physician lacked care or concern for the individual patient, seeing it as a sign of negligence.

Keep Relevant, Minus Irrelevant 

Including unnecessary details can waste time and reduce the efficiency of your documentation. Steer clear of repeating information that’s already known or irrelevant, as it can slow down the process. It’s also important to avoid adding any inappropriate details that could potentially expose you to legal issues.

Timely Documentation 

Creating documentation promptly is essential for defending a physician in the event of a malpractice lawfare. If the medical records are completed several days after a patient visit, it weakens the defense considerably. Timely note-taking or using a medical documentation solution with fast processing times is crucial for maintaining both the efficiency of your practice and its legal protection.

Pick a Documentation Solution that Fits Your Practice 

There are many medical documentation solutions available today. Whether you choose to use a traditional scribe, a transcription service, or a comprehensive documentation tool, it’s important to find one that suits your specific needs.

As you explore options for yourself or your practice, consider key factors such as cost, turnaround times, and data security. These elements can have a significant impact on the overall effectiveness of your chosen solution. 

10 Tips to Reduce Malpractice and Litigation Risks in Clinical Documentation  

The documentation can often be the key factor in determining the outcome of a malpractice case. When doctors tend to focus too much on how documentation affects E/M coding levels, worrying about Medicare audits and possible fines, they ignore the fact that the risk of a plaintiff attorney reviewing your records far outweighs the potential issues from an audit. When documenting patient visits, physicians should focus on being consistent and detailed.

Here are some straightforward suggestions to lower the likelihood of facing a lawsuit—and increase your chances of effectively defending yourself when the situation does arise.

1.  Always record vital signs, as their omission can be disastrous in “failure-to-diagnose” cases. In addition, document a thorough history and physical exam, including the patient's own descriptions of their history and current illness. Ensure that you write down all significant details, and standardize your procedures to confirm that key steps are always noted in similar situations. Any deviation from routine examinations should be carefully documented.

2.  Ensure that your notes are clear and legible. Avoid making inflammatory, judgmental, or derogatory remarks, considering that future readers of the record may include patients, other healthcare professionals, or legal authorities.

3.  Obtain informed consent for procedures, but don’t rely solely on a signed document. Make sure to document that the patient has been fully informed about the procedure, its risks, complications, and alternatives, and that they understood and accepted this information.

4.  Document all tests ordered or recommended, along with the results. If a patient is noncompliant, record this, along with your efforts to explain the risks of noncompliance. Additionally, note any insurance denials, the explanation provided to the patient, and your support for an appeal if appropriate.

5.  Never alter entries in the medical record. If possible, consider dictating your office notes in the patient’s presence, allowing you to clarify any concerns and prevent misunderstandings.

6.  Keep detailed records of phone calls with patients, ensuring all communication is properly documented. Follow up diligently with your patients to show thoroughness and protect yourself from potential lawsuits. This includes ensuring follow-up on test results, notifying patients of results (both positive and negative), and scheduling re-checks when you’re unsure about a diagnosis.

7.  Actively manage referrals, especially in high-risk cases, and ensure they happen by facilitating appointments with your office staff. For chronic conditions, develop a sensible schedule for follow-up visits, and actively manage any medication changes. Regularly review patient charts before visits and ensure smooth communication with anyone covering for you while you are off duty.

8.  Be vigilant in supervising non-physician providers, knowing your limitations, and refraining from performing procedures for which you have minimal experience. Avoid attempting procedures on noncooperative patients to reduce risk.

9.  Cultivate a patient-centered environment by maintaining good relationships with your patients. If there are delays, keep them informed with realistic wait times, and prioritize patients who need to reschedule. Give your full attention to patients during examinations, avoid interrupting, and ensure their privacy at all times.

10.Treat patients as individuals, not just medical conditions, and always involve them in decision-making. Maintain a respectful attitude toward previous treatments they may have received, and invite feedback on how to improve your practice. Follow up with any upset patients, and ensure staff are respectful and considerate. Lastly, maintain a warm, personable demeanor, as patients are less likely to pursue legal action against a caring professional.

Final Words 

Effective clinical care is a team effort with shared responsibilities between the patient and the physician. Together, they work to understand the patient's condition, discuss potential diagnoses and treatment options, and develop a plan that the patient agrees with. Medical records capture this collaborative process. By focusing on clear communication, you can improve patient-physician interactions, set clear expectations, and strengthen your defense against malpractice claims. Building effective communication techniques into your documentation practices ensures that information is fully shared, leading to better clinical results.

Like any system, the method of medical documentation operates without direct evidence proving its effectiveness. It is important for users of any documentation method to understand that, due to the emotional and financial aspects of litigation, as well as the varying interpretations of malpractice, no documentation system can fully protect against allegations.

Physicians can lower their chances of facing malpractice claims by consistently following up-to-date care standards, approaching patient evaluations with an open mind, supporting patient decisions, and viewing documentation not just as a task, but as a chance to highlight the high-quality care they deliver.