There are five reasons for medical documentation: 

1. Documenting current diagnoses, treatments, and recommendations for the patient to understand and implement.
2. Documenting current diagnoses and treatments for other clinicians to provide continuity of care, reduce duplication, and accelerate medical care among various trained specialists.
3. Documenting the level of services provided for billing purposes.
4. Documenting the level of services for quality improvement and overall patient health measures.
5. Documenting the services, thought processes, and recommendations to determine that the provider was practicing within a reasonable scope of practice when complaints at the licensing board or legal liability actions arise.

While the first four points are important, especially for payment, this article focuses on the fifth bullet point of establishing that a given encounter was within the range of acceptable practices, or the “standard of care.” More volume of documentation generally does not serve the fifth bullet point’s purpose well, but in many cases specific documentation is critical to defense. We often are looking in retrospect when care is in question for these very important “signals” which can be lost in the “noise.”

CRITICAL SIGNALS BASED ON SPECIFIC CLINICAL SCENARIOS
Informed Consent (Procedural)
In order to defend procedural cases, it’s critical to document the risks specific to the procedure as well as alternatives to the procedure. The informed consent document memorializes the informed consent process. From a legal perspective, patients (through their attorneys) often allege that they were unaware of the potential complications or risks, and that they were not provided any reasonable alternatives, if those exist.

Obstetrics Delivery
In cases of births involving a low APGAR neonate, or an operative vaginal delivery, shoulder dystocia, or a complicated pre-delivery course, there is a high likelihood of liability claims with high potential damage awards. Short, boilerplate notes are not appropriate in these cases, as they give the appearance that the provider viewed the case as routine and did not engage in detailed judgment and shared medical decision-making. It’s difficult to defend cases in which the notes are sloppy or inadequate, or are template-based delivery notes with no description of the provider’s thought process or judgment calls. 

The low APGAR neonate should contain a description of the labor process, any interventions or judgments made in the management of that labor, and a detailed note describing any and all maneuvers employed in the delivery. Cord gases, placental pathology, and early neonatal imaging are all important when neonates become symptomatic following complicated births. The operative vaginal delivery needs to describe the indications, the number of pulls, pop-offs (for vacuum), and other maneuvers that were applied. Shoulder dystocia needs accurate timing of the recognition and the sequential maneuvers applied to affect the delivery.  

Complicated labors with Electronic Fetal Monitoring (EFM) tracings need accurate and timely descriptions of the interpretation and the decisions made as a result of that interpretation, as tracings can be retrospectively interpreted differently to implicate a more distressed baby. It’s also important in this setting to debrief with the other members of the team, including the nursing staff, so that the team’s documentation is congruent and accurate.  

We are not (necessarily) advocating providers document this high level of detail for normal births, with high APGARs, and no shoulder dystocia or operative maneuvers. The documentation needs to match the risk of the obstetric setting.

Primary Care and Emergency Medicine
Our claims experience would indicate that the vast majority of medical encounters do not involve legal actions or questions about the standard of care of the provider, so voluminous documentation is unnecessary for defense purposes. However, high risk and complex cases such as acute neurologic presentations, chest pain, acute surgical abdomen, acute sepsis, high-risk infections, and high-mechanism trauma require higher levels of documentation. Here are a few “pearls” for documentation in these clinical presentations:

• In the acute neurologic setting, we often see inadequate neuro exams including true motor strength grading, lack of detail of sensory deficits, presence of true bilateral symptoms (for spinal cord lesions), and exam findings consistent with posterior circulation events. 
• Acute peripheral circulatory compromise, whether from trauma or chronic vascular disease, are also high-risk presentations for which the documentation is often either inaccurate or inadequate. Questionable vascular compromise should prompt subsequent Ankle Brachial Index (ABI), ultrasound evaluation, or consultation with orthopedic or vascular specialists.
• Vital signs are often incomplete, or when abnormal, lack documentation of the thought processes for the etiology of the abnormalities. Repeating vitals, attention to discharge vitals, and shortening the window for re-evaluation are all strategies for abnormal vitals. The respiratory rate is the vital sign most often absent, inaccurate, or ignored.  
• The mechanism of injury in the trauma, when known, drives the need for the complexity of the documentation. 
• Chest pain presentations can best be defended when standardized scoring measures, such as the HEART score, are used and documented. Similar measures exist for pulmonary embolism. Consider and document the thought processes for ruling out acute dissections.

Orthopedics
In addition to the informed consent comments previously mentioned, the need to evaluate and document your findings and decision-making in vascular compromise, compartment syndromes, and other serious complications in the post-procedure setting is critical and often missing or inadequate when we retrospectively are called on to defend your care.

Additionally, discussion and documentation of expectations setting are important, particularly in procedures where there is a reasonable likelihood that even a properly performed procedure will not significantly improve the outcome.

ALL CLINICAL ENCOUNTERS 
Detailed documentation of informal and curbside consultations by both the requester of the consultation and the provider of it are often missing or inadequate. The documentation should include the information conveyed, the decisions made, and who was assigned responsibility for the patient’s care, now and in subsequent follow-up.

Incidental findings require someone to “close the loop” with the patient about the nature of the abnormality, including why the recommended follow-up is important and the risks of not following up. Trusting the next clinician to provide the necessary follow-up on the incidental finding is often inadequate. Informing the patient and documenting the critical elements greatly adds to the defense when the patient alleges they were never told, and so suffered an adverse outcome such as a delayed diagnosis of a now more advanced malignancy.

When you receive critical lab, imaging, and other diagnostic findings, document what you did and what was communicated, including referring the patient for further immediate care. 

In legal cases viewed retrospectively, families and patients often allege that they stated something completely different than what the clinician or clinical team heard. One documentation strategy is to specifically state the patient's chief concerns and chief complaints verbatim and in quotes; such as “patient states (or chief complaint or chief concern)…” Recall that a chief concern is different than a chief complaint, but can provide insight into what the patient or family believes to be occurring. When their chief concern turns out to be accurate, and it was dismissed, ignored, or never heard, it can be difficult to defend the care.

HIGH-RISK REMINDERS ACROSS SERVICE LINES
Mentioned previously but deserving of repetition for all service lines is the need for congruent findings and documentation among multiple observers—medical assistants, nursing staff, and other providers. In cases involving adverse outcomes, there is often accurate information or findings by one member of the team that are critical to the outcome, but not widely communicated or documented by the people making decisions. 

When patients refuse your medical recommendations, we often cannot tell from the documentation whether the clinician described the benefits, risks, and alternatives of that recommendation to the patient. Patients can choose to refuse care after adequately being informed, and for that purpose COPIC has developed an informed refusal document. (Utilize your COPIC username and password to retrieve a sample form.)

CRITICAL DOCUMENTATION FOR YOUR BEST DEFENSE
Small amounts of critical documentation can often be your best defense. The specific scenarios and strategies for these critical documentation opportunities described previously are not an all-inclusive list, but represent a majority of the preventable issues in which our defense of your care could have been enhanced. There is much documentation noise that can serve the other purposes described but have little impact on your defense. We hope to improve the necessary signal, with the understanding of the vast amount of noise that can exist in the medical record.

Published: 1st Quarter 2023