If It Isn’t Documented, It Didn’t Happen
If It Isn’t Documented, It Didn’t Happen
Good record keeping protects patients and clinicians alike.
When it comes to professional misconduct, sex and drugs may grab the headlines, but a far less sensational issue derails a surprising number of medical careers. Texas-based healthcare attorney and PBI Education Faculty Member, Jon Porter, JD says poor record keeping is the most common violation he’s dealt with over the past 22 years, both as a prosecuting attorney for the Texas Medical Board and, since 2003, as a defense attorney in Austin.
“Don’t get me wrong,” says Porter, who teaches PBI Education’s course on Medical Records, “there are clinicians out there who do real harm to patients. But there are a whole lot more who are perfectly good practitioners who get into serious trouble because they fundamentally misunderstand the purpose and value of medical records.”
Good Record Keeping is Good Medicine
While medical records are important for a host of reasons, their primary purpose is to ensure continuity of care. For starters, that means they must be legible so other clinicians can read them. Regulators also want medical records to be completed promptly so nothing important is forgotten. Neither issue are much of a problem if that clinician routinely completes their notes before patients even leave the room.
Where today’s clinicians often fall short, says Porter, is attaining complete records. Regulators now insist that a record “stand on its own.” It’s not enough to jot down what happened during the current visit. Clinicians must include all relevant history, ensuring that the next clinician can understand everything that’s happened for the continuation of care. In the past, says Porter, “You could think of each visit’s notes as a chapter in a novel. Today, regulators want each individual record to be a short story, with a beginning, middle and end—complete and intelligible all on its own.”
Due to the impact of incomplete records on patient care, regulators take these matters seriously. If they find a record-keeping violation during an investigation, they will add these findings to the original complaint, regardless of whether they find evidence supporting the original charge. “Regulators view poor record keeping as a violation of the standard of care,” says Porter. “I’ve seen it many times over the years.”
Even simple mistakes can cause serious problems. Now that clinicians routinely use electronic medical records (EMR), many over rely on EMR’s auto-fill feature. Porter recalls going through a client’s records and noticing that the system had inserted a breast exam into his record for every single patient, male or female, regardless of age. When regulators see such carelessness, they begin questioning the overall accuracy of the entire record.
To demonstrate the confusion these mistakes can cause, Porter asked his client why he was completing a breast exam on every one of his patients, every time they came in. When the clinician indignantly denied the accusation, Porter suggested they go review his records. The clinician is a lot more careful now.
Good Record Keeping Protects Clinicians Too
Porter tells participants in the PBI Education Medical Records course that good medical records are not only good medicine, they are also clinicians’ first line of defense. It doesn’t matter what you say after the fact, he explains, “If it isn’t written down, it didn’t happen.”
Confronted by patients alleging mistreatment and clinicians denying it, regulators are inclined to believe the patients. Their mission, after all, is to protect the public, not the clinician. The best evidence clinicians can offer to support their account is the medical record they created at the time of the encounter. The same is true when insurance companies question clinical decisions or hospital administrators raise concerns about dissatisfied patients.
Regulators are especially keen to know that clinicians are keeping up with evolving standards of care. For instance, when treating patients with chronic conditions, clinicians must now be sure to document functionality. Before renewing an antihypertension drug, they must demonstrate that the patient’s blood pressure is within acceptable limits. If they continue a treatment plan for a diabetic patient, they must document that it’s having the desired effect. The only way regulators know clinicians are meeting this standard of care is by reviewing the medical record.
In addition, controlled substance contracts are another crucial form of documentation. They can take different forms, but the goal is always the same, to clarify upfront for the chronic-pain patient—or for patients taking psychotropic drugs—exactly what the clinician will and won’t do. A contract might spell out the clinician’s right to do random drug screens and how requests for early prescription renewals will be handled. It might also explain how the clinician will ensure that the patient isn’t hoarding or selling their medication.
In the end, medical record keeping does two things for clinicians. First, it helps ensure that other clinicians have the information they need to properly care for their patients. Second, it guarantees that regulators and administrators understand and appreciate the clinical decisions the clinician has made.
- Proper medical record keeping is vital to continuity of care.
- Good medical records must be legible, contemporaneous, and complete.
- To be complete, each medical record must document relevant history of present illness, the finds made by the clinician, the medical rational for the decisions made, oral informed consent and education, and a plan of care all justified by the documentation.
- Clinicians are responsible for all information in a medical record, including auto-populated fields.
- The medical record is a clinician’s first line of defense.
- Medical records allow clinicians to demonstrate that they are keeping up with changing standards of care.
- If it isn’t documented, it didn’t happen.
Visit our Medical Records course page for more information about our two-day Medical Record Keeping Course.
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