How complete and accurate are your patients’ medical records?
If you are sued for medical malpractice, the plaintiff’s medical records are typically the first thing your insurance carrier-appointed defense lawyer will request to review.
This article looks at the importance of having complete and accurate patient records as part of a risk management strategy to
- improve patient safety, and
- lower the risk of medical malpractice allegations
Your strategy should also include strong medical malpractice coverage from an “A” rated carrier – one with a track record of long-term financial solvency and providing robust financial and legal support for policyholders.
The Importance of “Precise” Patient Documentation
The Medscape-member physicians and specialists who participated in the Medscape Physicians and Malpractice Report 2023 were asked to suggest ways that doctors can control malpractice risk.
The top suggestions focused on keeping “good”, “precise”, and “exhaustive” documentation in the patient’s medical chart that “clearly distinguishes opinion from fact.”
Beyond improving patient safety, the study found that keeping accurate and precise patient records is especially important to a malpractice defense, especially if these three specific allegations are made against you in court:
1. Failure to diagnose or delayed diagnosis
Medscape’s 2023 report indicated that failure to diagnose or delayed diagnosis continues to be the top allegation reported by physicians year after year. The top three diagnostic allegations cited most often are:
- misdiagnosed cancers
- vascular events, and
Such errors and delays can be caused by failure to document specific symptoms, delays in reviewing diagnostic test results, poor communication between the patient’s doctors and specialists, and failure to document the patient’s past medical history.
2. Improperly obtained or lack of informed patient consent for treatment
Allegations of failure to obtain the patient’s informed consent to be treated can only be disproven when all details of the patient interaction and signed consent form are dated and documented properly on the patient’s medical record.
3. Errors in medication administration
Lack of communication between doctors and medical staff, inaccurate or missing medication documentation on the patient’s chart, and failure to regularly update the patient’s medication list can result in medication errors that lead to poor or even fatal patient outcomes.
Medical Record Management Best Practices
Take these steps now to reduce your risk and improve your medical record management:
Healthcare organizations such as Johns Hopkins Medicine, the American Medical Association, and the American Academy of Family Physicians have developed some best practices to help physicians document, update, and manage complete and accurate patient records. For example:
Document and summarize each patient’s visit separately and with as much detail as possible of the types of doctor/patient interactions that occurred – especially written and dated confirmation of the patient’s signed informed consent for treatment.
Keep all documentation of a patient’s visits and treatments in chronological order to show continuum of care for the patient’s condition.
Sign and date every note, documentation, addendum, and correction in the patient’s record. Ensure that handwritten notes and signatures are legible. Electronic health records should include a digital signature and date stamp.
Establish a policy that patient records cannot be accessed or altered by unauthorized staff.
Also, ensure that the patient’s medical record contains precise and timely documentation of the following:
Accurate and up-to-date list of prescribed medications, including pharmacy printouts for each. Documentation that the patient understands how to take the drug and is compliant with taking it. Include all known drug interactions and the patient’s allergies to the list.
Results of tests, labs, and screenings with documentation that shows the date and time when the tests were ordered, results received, and when the patient was notified of the results. Also documentation of any consultations/communications with radiologists, specialists, and other providers on the patient’s care team.
In high-risk cases such as heart attack, breast cancer, colon cancer, etc., include documentation of advice given to the patient, steps in your approach to the diagnosis, and the details of the follow-up plan for the patient.
Copies of the patient’s signed and dated informed consent for treatment forms, plus signed and dated documentation that all of the benefits and possible risk factors were discussed with the patient before the treatment.
Your Best Risk Management Strategy: Accurate Patient Records AND Strong Medical Malpractice Coverage
Even if you have not yet been sued for medical malpractice, adopting best practices for accurate and complete documentation of patient records will contribute to improved patient care and outcomes – and that can translate to lowering your risk of malpractice allegations.
You’ll also need strong medical malpractice insurance in place to further lower your risk of financial loss in case a lawsuit is brought against you. Let MEDPLI be your only trusted broker to help you find robust medical malpractice coverage and tail insurance from A-rated carriers.
Get a quote from an independent MEDPLI insurance broker now or call 800-969-1339.