Documentation, or failing to document, can lead to a lawsuit or board matter. Your record may be critical. It may be reviewed by your attorney, the opposing attorney, and, depending upon the issue, the board investigator or a jury, as well as the patient and his/her family. Improper documentation can lead to license restriction, revocation, or restriction by a licensing board. It can also result in an inability to defend a lawsuit. The medical record can also be used as evidence either to support your or your patient’s case.
Keep in mind that the medical record is a legal document, and it is important that your documentation is thorough. You may or may not even remember the patient when the care is being examined, and it might be years after your encounter. Thus, it is important that your documentation reflects the care provided, the issues addressed, and that it is a factual account of what occurred.
Documentation should adhere to applicable regulations, accreditation standards, and professional practice standards. Be aware if your state has set regulations regarding documentation. If you fail to adhere to applicable regulations, the licensing board may take action, and also this failure may be used by the opposing attorney to support a lawsuit. Always remember how your documentation, or lack thereof, would appear blown up on a screen in front of a judge or jury. Would it appear professional and reflect the care provided?
Be sure to check your profession’s ethical guidelines on documentation principles. When you have questions, it is best to consult an attorney for guidance.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust Companies is strictly prohibited.