Charting Practices to Protect Against Malpractice: Case Reviews and Learning Points

Abstract

Introduction: Medical documentation issues play a role in 10-20% of medical malpractice lawsuits. Inaccurate, incomplete, or generic records undermine a physician’s defense and make a plaintiff’s lawyer more likely to take on a case. Despite the frequency of documentation errors in malpractice suits, physicians receive very little education or feedback on their documentation. Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians’ documentation and minimize their liability risks. Methods: We used Thomson Reuters Westlaw legal database to identify malpractice cases related to documentation. Common issues related to documentation and themes in the cases were identified and highlighted. Results: We classified cases into the following categories: incomplete documentation; inaccurate text; transcription errors; judgmental language; and alteration of documentation. By evaluating real cases, physicians can better understand common errors of other practitioners and avoid these in their own practice. Conclusion: Emergency physicians can reduce their liability risks by relying less on forms and templates and making a habit of documenting discussions with the patients, recording others’ involvement in patient care (chaperones, consultants, trainees, etc.), addressing others’ notes (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated information, avoiding judgmental language, and refraining from altering patient charts.

Characterizing malpractice cases involving emergency department advanced practice providers, physicians in training, and attending physicians

“…Documentation was noted to be an important contributing factor for malpractice claims that substantially involved NPs, PAs, and trainees (Table 3). Documentation is a commonly cited reason for malpractice risk and degree of supervision varies greatly among individual attendings, departments, and states 20 . A lack of sufficient oversight and poor standardization of supervisory workflows may contribute to malpractice risk for trainees, NPs, and PAs.…”

“…Documentation is a commonly cited reason for malpractice risk and degree of supervision varies greatly among individual attendings, departments, and states. 20…”

How Might Antibiotic Stewardship Programs Influence Clinicians’ Autonomy and Organizations’ Liability?

“…Indeed, good documentation by ASPs and their personnel-as well as by primary clinicians-and explaining and justifying assessments and recommendations might mitigate possible malpractice liability while also promoting clinician autonomy, especially in the event of disagreements. 20 On the other hand, minimizing clinicians' ability to disagree with specialists or the ASP could channel liability to one decision maker-namely, to a specialist or to the ASP.…”

A Hospital Medical Record Quality Scoring Tool (MeReQ): Development, Validation, and Results of a Pilot Study

“…Hospital medical record review is a vital process in medical malpractice lawsuits [6][7][8] and is a fundamental document that reports the events that occurred during the patient's hospitalization, including the drugs administered, the interventions performed, and the patient's health status on a daily basis, at the time of hospitalization and discharge. It is crucial to have precise documentation of the medical procedures performed on the patient, the information conveyed to them, and the time and location of the procedures in case of a legal dispute, also considering that hospital medical records are used in courts of law [9].…”