Ashley Weber, BSN, RN, LNCC

There is no substitute for a detailed medical record. A detailed record can refresh a provider’s memory of a patient’s history, physical findings, interactions with the patient, and the thought processes behind care decisions. It also helps to protect the legal interests of the patient, healthcare entity, and health professionals^[1].

A Malpractice Lawsuit and the Medical Record

In a medical malpractice lawsuit, the medical record is primarily seen as unbiased documentation of the patient and their care with no thought to legal or court actions. When introduced as evidence, complete records can offset patient allegations that a physician was negligent in making medical decisions and providing treatment. This evidence is extremely valuable and used both inside and outside the court to settle disputes, such as assessing the extent of injury in accident cases or establishing the presence or absence of negligence of the health professional or entity in the patient’s treatment.

The Cost of Errors in EHR Documentation

When using electronic health records (EHR) to document care, errors in the medical record have resulted in medical malpractice claims of more than $61 million. A recent survey identified safety concerns connected to EHR, including errors in patient identification, incorrect selection from a list of items, and open or incomplete orders^[2].

Common EHR Documentation Errors

The American Health Information Management Association position paper entitled “Appropriate Use of the Copy and Paste Functionality in Electronic Health Records” outlines the risks and challenges associated with the use of copy and paste in an EHR, including:

• Inaccurate or outdated information
• Redundant information, which makes it challenging to identify the current information
• Inability to identify the author or intent of the documentation
• Inability to identify when the documentation was first created
• Propagation of false information
• Internally inconsistent progress notes
• Unnecessarily lengthy progress notes

Ways to Minimize the Risk of Errors

Fifteen percent of malpractice cases involve pre-populating and copy and paste as contributing factors. Ways to minimize the risk of copy-paste errors include:

1. Limit the type of content that can be copied in the EHR.
2. Routine reviews of EHR entries are needed to ensure that the EHR accurately reflects the care provided during the encounter and does not contain clinically irrelevant or anachronistic information^[3].

Ways to Improve Documentation

Focusing on objective clinical information, using clear, professional language, and proofreading tend to strengthen clinical documentation (see the title of this article). Subjective, critical, demeaning, or otherwise unprofessional tones can alter a jury’s perception of the healthcare provider^[4].

1. Emphasize objective and constructive clinical information that contributes to safe and effective care and avoid expressing subjective criticism of another provider’s care.

2. Focus on individualized care, avoiding dependence on computer-generated documentation.

3. Follow your organization’s policy on the use of acceptable abbreviations.

4. Document promptly. The more time between providing care to documenting the care, the less reliable the entry becomes.

5. Avoid documenting before providing care.

6. Authenticate the date and the time of your entries.

7. Document all efforts to communicate with the patient. Include communication with the patient outside the medical record system, such as phone calls, emails, text messages, or any other form of correspondence sent outside of the formal medical record.

8. Avoid making changes to medical records after learning of a lawsuit, as this may cause others to raise questions about honesty, motives, and the quality of care.

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_{[1] International Federation of Health Information Management Associations. (2018, December 17). Retrieved from IFHIMA: https://ifhima.org/wp-content/uploads/2014/08/module1the-health-record.pdf
[2] ECRI Institute. (2015, May). Wrong Record, Wrong-Data Errors with Health IT Systems. PSO Navigator, 7(2), 1-10.
[3] 3M Health Information Systems. (2018, 12 17). Retrieved from 3M: http://multimedia.3m.com/mws/media/1048497O/3m-360emd-copy-paste-white-paper.pdf
[4] Guthell, T. (2004, November). Fundamentals of Medical Record Documentation. Psychiatry.}

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About the Author
Ashley Weber BSN, RN, LNCC is a KAMMCO in-house registered nurse reviewer who prepares chronologies and memos for the defense of medical malpractice claims. She also spearheads the medical research program available in the defense of claims. She has over 10 years of experience as a registered nurse with over half of that time focused on legal nursing. In 2019, she earned her LNCC designation from the American Association of Legal Nurse Consultants.