Proper documentation is a necessary component of modern health care. Diligent documentation is essential for more than just good patient care. It is also the surest way to protect your professional future. In fact, most third-party insurers require documentation for payment. In short, if you didn’t document it, it didn’t happen.

I advise my clients to document all conversations, procedures, mistakes, and guidance from supervising physicians or consulting physicians.  It is unfortunate how willing many employers are to throw their PAs or NPs under the bus when a malpractice suit comes to light. Any interaction with a supervising physician regarding a patient must be documented.

Keep the following three principles in mind when treating a patient:

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Documentation is required for good patient care

Never forget how much we rely on the medical record and how frequently other providers will use the medical record to determine future care. This brings us to the issue of legibility – if no one can read the medical record it’s almost useless to future providers and the patient.  I know it sounds obvious, but always write clearly.

Documentation may save your job

In a malpractice suit, the patient record will determine a large portion of the outcome. Did you document that you told the patient about potential side effects? Informed consent? Other treatment options? Did you examine the lymph nodes found no swelling? Document everything you did and ever conversation you had. Never change a medical record after you’ve been alerted to a potential medical malpractice suit. Also remember not to write anything in the chart you wouldn’t want the patient or a judge to read.

Documentation is required for billing purposes

Most third-party payers can request chart notes or, as is the case with Medicare, perform audits on your charts. In the event of insufficient documentation, they can deny payment, request payment back, or issue a fine. Understand what is required for different billing codes. For example, what makes a 99213 office visit different from a 99212? If you bill the higher level (99213) you better have documentation to support the charge.

Many clinicians consider documentation and charting one of the least enjoyable aspects of our jobs. Hopefully, as more electronic medical record programs emerge, this aspect of the job will get easier. In the meantime remember these three words: DOCUMENT, DOCUMENT, DOCUMENT!

Ms. Jacobson practices dermatology in Lancaster, Pa. She is also the owner of Strategic Medical Consulting, LLC and