I am a family nurse practitioner and, for the last few years, have also been working in the field of life care planning. At its heart, this involves planning for the care needs and associated costs related to a catastrophic injury or chronic illness. My work has been in the legal realm and involves reading thousands of pages of medical records and depositions. Some clear patterns in documentation, or lack thereof, have presented themselves in the course of this work. As clinicians, we know what and how we should be documenting in medical records; however, in practice, that we are not documenting consistently enough.  

Even beyond the call to adhere to best practices for the sake of form and propriety, providers should bear in mind that there perpetually exists the possibility of being called in for a deposition or even a trial. Should one of your patients pursue a personal injury or medical malpractice lawsuit, regardless of whether that suit is related to your care, you may be deposed and your clinical notes will take on entirely new relevance. The following are 5 tips on documentation best practices.

1. Document Your Examination

Failure to document a physical examination is the most common mistake I see. We may be missing this step when documenting hours, or possibly days, after seeing the patient or forgetting to change the electronic medical record (EMR) default. Either way, failure to document your physical examination findings can be your downfall. I have read the depositions of multiple providers who did not document the exam they are certain they performed. The obvious question from an attorney is, “if you forgot to document your exam, what else did you forget?” It opens the window to a huge amount of doubt regarding the provider’s credibility.

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2. Know What Information is Prepopulated in Your Electronic Medical Record

Using an EMR template is helpful and fast, but you must know what is prepopulated in the note and remember to make changes specific to your patient. When your template automatically includes the detailing of normal examinations and review of system (ROS) elements, even if you include alternative findings at the end of the exam or in paragraph form, you need to uncheck, delete, or change parts of the exam in the template that were not normal or not relevant to the chief complaint. Findings need to be consistent throughout your note. Leaving the original normal entry when it contradicts the chief complaint, exam findings, or assessment and treatment plan leaves room for questioning and doubt.

3. Beware of Copying Prior Visit Notes

While the ability to copy the last visit note is helpful when documenting visits for patients with chronic issues, it is vital to read the updated note. What may often be a useful time-saver can turn into a liability when forgetting to update the old note brings your accuracy into question. Copying notes often leads to the inclusion of inaccurate timeframes for issues or illnesses, incorrect review of symptoms or physical exam documentation, or a plan that is no longer applicable. Don’t leave yourself open to questions about whether you actually prescribed an acute or controlled medication again, or why you didn’t update your plan according to new information.

4. Document Communication Outside of Visits

If you send a patient a letter with their results, called them to discuss a finding, returned a call with a question, or had any other form of communication outside of an office visit, make sure the interaction is documented or copied into their chart. Ensure that your support staff is following the same protocol. It is so easy to forget or let small conversations go without documentation; however, being able to prove that you did not ignore a patient and communicated with them effectively is crucial if you are deposed.

5. Write Down Future Plans

We often don’t think about who may be reading our notes after we sign them. When medical care is transferred, life care planners as well as social workers, specialists, and additional providers need this information to plan and coordinate care. Clinicians often know what steps they will take for patients at the next follow-up visit, and documenting this plan can be extremely valuable during care transitions. Examples of such documentation include “Follow up in 1 month regarding change in losartan dosage and then resume routine follow-up every 3 months” or “will begin sitagliptin for diabetes management today and discussed with the patient that insulin management may be needed if this is not effective.”

The bottom line is that most of us are providing excellent care to our patients and we need to be sure this is reflected in our charting. A lawsuit regarding any aspect of a patient’s health can bring your documentation under scrutiny — make sure it holds up!

Lisa Gay, MSN, RN, FNP-BC, CLCP, is a family nurse practitioner at Plessen Healthcare in St. Croix and certified life care planner at Case in Point, LCP, based in Florida.

The author would like to thank Keeli Fricks, who provided general editing services and assisted with content clarity for this article.