Manage Medical Risk with These Guidelines for Medical Documentation

May 12, 2022 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Practice Management

Even in today’s increasingly complex healthcare environment—where technology and new laws impact almost every aspect of medical billing and practice management—one of the most valuable tools to protect your practice is the most simple: your pen.

Each medical record in your office is a living legal document that could be read aloud in a courtroom should that situation ever be presented to your practice. Ensuring that all of the documentation inside them is thorough, accurate, and legible should be a primary concern for every medical practice, but it’s not typically prioritized. After all, how often do you review the completeness and quality of your medical documentation?

Medical documentation plays a crucial role in risk management for medical practices; keep reading to learn the foundational elements of this relationship between documentation and risk, and the do’s and don'ts of medical documentation in your practice.

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What Is Medical Documentation?

As you might have guessed, medical documentation entails any material relating to a patient’s health record or chart. There are various types of medical documentation that pertain to a patient’s health, including:

  • Operative notes
  • Progress notes
  • Physician orders or certification
  • Physical therapy notes
  • ER records
  • Discharge summary
  • Mental status examination
  • Medical test


Medical documentation is vital for your medical practice

Since medical documentation takes many different forms over the course of a patient’s wellness journey, it’s vital that any notes, conclusions, events, etc. are clearly and consistently documented. A good rule of thumb is the phrase “If it’s not documented, then it didn’t happen or doesn’t exist” because this underlines the importance of good documentation habits. 

Medical documentation serves many essential functions including medical billing processes—after all, CPT codes and ICD-10 codes must be supported by documentation in a patient’s record—serving as evidence in legal situations, and more. 

Of course, the most critical role that medical documentation plays in a practice’s operations is facilitating clear communication regarding a patient’s history of care. In order to deliver quality care to a patient over the course of different providers, it’s necessary to have good medical documentation and provider notes. 

How Does Documentation Affect Risk in Your Medical Practice?

If good medical documentation habits lead to good patient care, then, conversely, poor medical documentation can lead to poorly informed providers who can, unintentionally, deliver care that might lead to an exacerbation of the patient’s status or even legal trouble.

Since a patient’s medical record provides the history of each patient-provider interaction, it can serve as evidence in a legal proceeding. Making informed decisions for the patient is predicated upon knowing the accurate and complete account of a patient’s record to give the provider adequate context to their individual situation. As such, medical documentation is liable to be heavily scrutinized and reviewed in the confines of a courtroom.

That’s why it’s important that you and the colleagues at your medical practice employ good medical documentation habits by documenting discussions, interactions, diagnoses, treatment decisions, and more in a transparent and consistent manner.

Do's and Don'ts of Medical Documentation

Whether you use electronic health records, paper charts, or both, it’s crucial to revisit your documentation processes and procedures regularly to ensure that you’re keeping your malpractice risk to a minimum. Here are the keys to keep in mind:

Do Utilize Transcription Technology

Having your providers dictate their notes into a recording device, then using transcription technology to turn the tape into documentation, is a smart strategy. Dictated notes help you ensure that the medical record has the “horse’s mouth” version of what happened in the exam room. 

But Don’t Think Dictation is All You Need

Issues can arise from relying solely on transcripted notes, especially if transcription quality is poor or the doctor dictates too much or too little information. Know that all transcripted documentation should be reviewed before going into a medical record.

Do Integrate Your EHR System

Your practice’s EHR system is a fantastic resource for medical documentation because it keeps everything related to a patient centralized for easy access and comprehensive care. Providers can share electronic medical records with other authorized parties for collaborative care when treating a patient from a holistic perspective and it reduces errors in miscommunication or illegible handwriting.

But Don’t Rely on Templates or Autofill

Some EHR systems allow providers to use different templates or generate automated content to fill out the template. This is risky because it might mean that a prior patient’s notes are simply copied and pasted into another patient’s record or the autofilled content doesn’t accurately reflect the patient’s encounter. Relying on these templates or automated content won’t ensure that specific information is recorded that will help deliver quality care, and multiple patients with the same “notes” could be damaging in a courtroom.

Do Avoid Omission

All information relevant to a patient’s care should be documented, as should the rationale behind a doctor’s choice to pursue a given treatment path. Make sure you’re noting all discussions regarding patient education and consent, visitors to the patient, follow-up instructions, recommendations, test results, etc. for a comprehensive picture of the patient-provider account.

But Don’t Include Everything

Non-clinical concerns, even some that feel relevant to the encounter, should stay out of the patient record. Avoid including any criticism of the patients’ prior care, any self-serving or accusatory language, or any derogatory or subjective comments. Be sure to also refrain from using sarcasm or cracking jokes in the notes, as these never translate well to the courtroom.

Check out our tips for good medical documentation practices

Do Get the Help you Need

If you think your documentation is lacking, it’s wise to recruit help. Many practices use medical assistants or other personnel as scribes, tasking them with taking notes of the patient visit and/or comparing them to the transcripted notes. Plus, having a scribe in the exam room also lowers practice risk by making another party be witness to each encounter.

But Don’t Go ‘All Hands on Deck’ 

Recruiting a scribe or training a qualified staffer to become one is different from throwing a random team member into the exam room and asking them to take notes. Don’t let anyone be involved in the documentation of an encounter without equipping them with education beforehand especially because this can lead to too much or too little information being recorded, which, of course, impacts the quality of patient care later.

Do Keep Copies 

In most instances, it’s wise to keep items in the record that relate to communications with your patient. Note or keep copies of the follow-up instructions delivered to patients and include printouts of any emails and all reports of tests and consultations.

But Don’t Use the Record as a Catch-all

Be mindful of things that aren’t medical and thus don’t belong in the medical record. For example, it may make sense to you to include or make mention of any event reports related to risk management issues—since the medical record is a legal document—but doing so isn’t appropriate. Make sure only clinically pertinent information gets documented in the medical record.

Partner with NCG to Help Streamline Your Practice & Reduce Risk!

Working with patients to deliver quality care takes time and attention—not to mention ensuring that all pertinent medical documentation is relevant, complete, and accurate. Give yourself and your staff more time to focus on these important tasks instead of medical billing and coding. Partner with NCG Medical to handle a vital part of your revenue cycle that ensures you have minimal rejected claims and get paid with prompt claim submission!

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