How EHR Documentation Practices Directly Affect Medical Liability
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In the event of a medical malpractice lawsuit, a physician’s defense relies primarily on the documentation of the care they provided. In the healthcare industry, it is often stated, “If it isn’t documented, it didn’t happen.” While Electronic Medical Records (EMRs) have introduced improvements in healthcare documentation, Candello’s 2024 Benchmarking Report on Documentation indicates that the likelihood of a medical professional liability (MPL) case closing with an indemnity payment increases by 140% when there are indications of inadequate documentation of patient encounters. Furthermore, the cost of defense significantly escalates due to the difficulty in securing defense experts and the necessity for depositions to establish the standard of care. The same 2024 Candello Benchmark Report also noted that documentation cases that do not result in payment, i.e., in which the care is successfully defended, took longer to close than cases without documentation issues (2.5 vs. 2 years).
Effective documentation is not only a legal safeguard but also a critical component of patient care. Proper documentation ensures continuity of care, supports clinical decision-making, and enhances communication among healthcare providers. It serves as a comprehensive record of a patient’s medical history, treatments, and outcomes, which is essential for delivering high-quality care. Inadequate documentation, on the other hand, can lead to miscommunication, errors in patient care, and increased liability risks. Therefore, healthcare providers must prioritize accurate and thorough documentation to mitigate legal risks and improve patient outcomes.
Upon closer examination, the following documentation errors were identified:
- Missing Documentation
- Cut and Paste
- Dictation Errors – primarily enunciation errors and deletions
- Consulting Providers – formal vs. informal consultation
- Chart Alterations after an Unanticipated Event – avoid doing this
- Discharging Against Medical Advice – AMA forms are not sufficient; document your discussions with the patient
- Incorrect Documentation – e.g., documenting in the wrong patient chart
- Stigmatizing Language
- Discharge Instructions and Post-Discharge Communication – document discharge instructions and post-discharge phone calls
MIEC has always recognized that the best defense depends on the documentation of care. While many of these errors are relatively easy to make, taking the time to ensure complete and accurate documentation is crucial. To avoid some of the pitfalls mentioned above and to reduce the risk of an adverse outcome for a patient, consider these best practices:
- Forms and templates are important but strive to document your discussions with the patient.
- Address other practitioner notes, such as those from consulting providers, mid-levels, and nurses. This demonstrates that you have reviewed and acknowledged the input from the care team.
- Review all transcriptions for accuracy. Despite advances in technology, physicians are still accountable for the accuracy of their dictations.
- Avoid judgmental language, especially documentation that is not medically necessary or clinically irrelevant, such as political, economic, or religious views of the patient.
- Finally, if you are involved in an event where the patient suffers an unanticipated outcome, do not alter or delete existing records. Alterations to the medical records after an event are easily identifiable through EMR metadata. Strive to document all relevant medical findings and care during the initial encounter.
As always, if you have questions about documentation practices, please contact MIEC’s Patient Safety Risk Management team at patientsafetyriskmgmt@miec.com.