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Three Steps for Creating an Accurate Patient Record ​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

An accurate patient record not only promotes optimal patient outcomes and provides backup for billing decisions so you obtain full reimbursement; it’s essential to protect you and your staff from lawsuits. If litigation occurs, an accurate patient record is an invaluable resource for your defense attorney. 

 

Here are three steps you can take to ensure your records meet the needs of patients and your organization.

Step 1: Set policy

Evaluate your documentation policy to ensure that it covers key points. The policy should reflect the fact that the patient record must be highly detailed. Without sufficient detail, an attorney will be unable to provide an adequate defense should your staff or organization be sued. 

Your policy should also reflect national standards for your industry. Also consider rules and regulations in the state where the business is located and scope of practice for those working in your organization.

One of the first items an opposing attorney checks is whether the staff member was following standards and functioning within his or her scope of practice. If not, that becomes a key element of the case.

Step 2: Educate staff

It’s not enough to simply put a policy in place. You need to educate your staff about it. Hold education sessions where staff can practice their documentation skills. For instance, provide a patient situation and ask staff to document it. Then hold a group discussion about what the best entry would be. 

As with any education endeavor, you need to share why it’s important to have an accurate patient record. Link good documentation to quality care and to protection against litigation. Discuss timesaving techniques staff can use such as documenting as they go or dictating into a tape recorder and transcribing the information later.

Step 3: Follow up

Don’t assume that staff are following the policy. Put in place an audit mechanism where patient records are analyzed against criteria based on your policy. Provide feedback for those who aren’t performing adequately, and verify their improvement.

Do’s and dont's

An accurate patient record contains information for each patient visit, including your observations and recommendations, actions you took, and future plans. Keep in mind that these notes must clearly show what happened to the patient and what is planned for the future so other staff can sufficiently understand the treatment plan. 

In addition to helping the patient, an accurate record protects you in case of legal action. Follow these documentation tips to create a quality patient record.

Do chart promptly. Otherwise, you’ll tend to forget key details. If necessary, dictate into a tape recorder and transcribe your notes later.

Do be thorough when making each entry. Include reasons for choosing a particular device, adjustments made, education provided, and any other actions taken. It’s better to have too much information than not enough.

Do document any communications you made to other clinicians such as the patient’s physician and the results.

Do follow your organization’s policies for documentation. 

Do keep all supplemental documentation such as prescriptions from the patient’s primary care providers.

Do keep all documentation in one file so you can easily access it. Do keep billing information in the same folder but separate from clinical information.

Don’t squeeze in words or skip lines. With each entry, draw a line through unused space.

Don’t alter entries—any attempt to erase an entry or write over it is a red flag to an attorney. If you have to make a correction, draw a line through the entry and write “error” along with your initials. Then make the correction with the date, time, and your signature.

Protect your staff and your organization

By putting a policy in place, educating staff, and auditing, you can ensure you have a patient record that protects your staff and your organization from legal action and serves as the front line of defense in court.

By Cynthia Saver, MS, RN, President, CLS Development, Columbia, Maryland.​

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