With the number of clinical hospitalists still growing, more patients are under HM care, which puts hospitalists at higher risk for lawsuits. The goal for a hospitalist should be to take care of their patients, but at the same point make a defensible medical record. Plaintiffs’ attorneys look for potential red flags in the medical record. Potential red flags could be illegibility, omissions of date and time, criticism of other healthcare providers, vague terminology, abbreviations, delayed entries, inconsistencies between healthcare providers, corrections, and opinions about the patient.
The medical record is a legal document that is required by law and regulatory bodies. It serves as a communication vehicle for healthcare providers; it tells the patient’s story as well as the care that has been received. It is used for implementing quality-improvement initiatives, determining appropriate level of care, and research and education. It also is the most credible evidence in a legal proceeding. Inaccurate or incomplete documentation can mean serious trouble.
The most common documentation error is illegible handwriting. It is well known throughout medicine that if it’s not documented, it has not been done. At the same time, what is not readable has not been done. Electronic health records (EHR) have minimized this problem; however, EHR is not universally available, and documentation could include both electronic and handwritten entries.
Common sense dictates that all records should be legible, but it is surprising the number of progress notes that are illegible. Physicians are encouraged to write in black ink, so that the notes are capable of being photocopied. Some colored inks can run when they become wet. Also, all entries should include the full date, time, and the name of the physician, as well as their title and designation, which should be printed alongside their signatures.
Correction fluid must not be used in any patient records. Corrections should be made with a single line drawn through them, initialed, dated, and timed, so the error can still be read. All entries should be in a chronological order, with no spaces between the entries. Extra words should not be squeezed onto a line; a line must be drawn through any empty space at the end of an entry. Ditto marks should never be used. Use of glue is not permitted in the medical record, unless some special pages have tabs to allow sheets to be attached to the notes.
No paper should be removed from the clinical file, other than for purposes of photocopying, and those should be returned immediately. Each page of the documentation should be sequentially numbered; if the pages are kept in separate sections, make sure that is clear. Each progress note should have three unique patient identifiers: patient name, date of birth, and a record number. Most hospitals use sticker systems or printable progress notes, which have taken care of this problem.
Notes from various specialties, including nursing records, should be documented in the patient chart. If any of these include discussions held outside of normal working hours, those entry notes should clearly state the time and location of the discussions and state that the entry is made retrospectively.
Leaving space to accommodate late documentation never is a good idea. If the space is too small and subsequent documentation is squeezed in, an attorney could allege that the squeeze documentation was added to cover something up. If the space is too large, the blank space remains unaccounted for. When a late entry is made several days later, it should include a rationale for the delay. Unexplained late entries, along with erased or obliterated entries, are serious red flags.