Good documentation in the patient’s record can be a primary defense against allegations of malpractice. A well-documented patient record may actually prevent a lawsuit from being filed. On the other hand, poor documentation or alterations in the patient record can render an otherwise defensible case indefensible. Patient record documentation should accurately reflect the care and treatment provided to a patient and that the standard of care was rendered. Good documentation is also crucial in the coordination and communication of patient care with other healthcare providers and to justify billing. Documentation should be legible, accurate, clinically relevant, chronological, objective, clear, complete and specific.

Resources:
Video: Make Your Documentation More Meaningful for You and Your Patients

A common mistake is not editing a template so that it is patient-specific, which results in documentation of information that is erroneous or doesn’t apply to the patient. For example, when using a template for the initial history and physical, the template states the patient has a normal gait, but in reality, the patient has an antalgic gait due to pain.

Another common problem is carrying forward the initial history and physical to subsequent visit notes when another history and physical was not performed. By including the history and physical, you imply that you performed a history and physical on that visit. Instead document any changes to the initial history and physical or that the history and physical are unchanged. The progress note should only include documentation of the service(s) that you provided on that visit.

Some pre-fabricated templates contain a large amount of extraneous information that does not apply to the reason for the patient’s visit or plan of treatment. For example, documentation that the patient is “well-developed, well-nourished and with good attention to hygiene and body habitus” and “oriented to person, place and time” in every progress note when there is no history that the patient ever had a problem with hygiene or cognition is ill advised. Documentation containing a large volume of information that does not relate to the specific patient or the patient’s complaints is difficult to read and may prove less effective that a simple record which is clinically relevant and accurately describes the patient’s condition.

Also, review your notes for inconsistencies prior to locking them in. For example, if the template notes state the patient does not have a fracture, but the diagnosis is documented as “fracture”, does the patient have a fracture or not? This could have implications for the patient’s care and treatment and could also have a major impact on the ability to defend your actions in a malpractice action.

In addition, improper or careless use of templates may lead to allegations of fraud and abuse in Medicare, Medicaid, and private insurance audits and investigations. Efforts should always be made to customize the documentation of each patient encounter.

Electronic templates should be considered a framework upon which you document. They should contain a standard structure to allow you to construct a chart note that accurately reflects the events of the clinical visit. Only bring in the information that is relevant to the visit of the day and make sure that any new diagnostic test, X-ray or consultation results are addressed.

It is important to document that you acknowledged the alert and took appropriate action. At the same time, the process should not be unnecessarily burdensome for you or for the prescribing doctor.

You should discuss with the patient that a potential drug-drug or drug-allergy interaction was noted by your EMR software and advise the patient to speak to the prescribing doctor regarding the potential interaction. This conversation should then be documented in your progress note. One option is to create a template for this purpose. For example, “Upon updating the patient’s medication list in the EMR, an alert was displayed on a potential [drug-drug, drug-allergy] interaction. The alert indicated that the nature of the interaction is [nature of interaction]. This medication was prescribed to the patient by another doctor. The patient was notified of the nature of the potential interaction and advised to contact the doctor who prescribed the medication(s) to discuss the potential interaction.”

If the alert is classified as moderate or severe, you could also send the prescribing doctor a letter such as, “Upon updating [patient’s name] current medications list, the patient provided us with the following medications: [list medications]. Our EMR software alerted us to the following potential drug interactions: [list potential interactions]. As part of our medication reconciliation and doctor communication process, we are sharing this information with you. If you have EMR software installed in your practice and have the capability to accept Continuity of Care Document (CCD) files*, please let us know so that we may efficiently communicate with your office electronically in the future.”

*CCD is an electronic document exchange standard for sharing patient summary information.

There are valid instances when correction of an erroneous entry, late entries of necessary clinical information, addendums to prior entries or amendments to the patient record need to occur. In these instances, appropriate steps should be taken to clearly document who made the entry, when the entry was made and why the entry was made.

Changes to the patient record should not be made after the record has been copied and released, such as to an attorney. Any changes to a record after a copy has been released results in two versions of the record. In the event of a lawsuit, suspicions of record alteration will be raised. Any hint of record tampering may completely shatter the credibility of the record and of the defendant and may lead to a plaintiff’s verdict, regardless of the medical facts or merit of the case.

Never alter a patient record. If it is determined that patient records have been changed without justification, the credibility of the entire record may be destroyed. Not only will record alteration severely damage the chances of prevailing in a lawsuit, but it may put professional liability coverage for the incident at risk.

Resources:
Video: How Do I Correct an Error in a Patient's Medical Record?

As soon as possible after discovering an unexpected outcome, document the event in the patient’s record. Documentation of unexpected outcomes should be factual. The documentation should not contain subjective comments, blame or speculation about what happened. The provider should document times, observations, and communications from the patient, and any follow-up communications from the provider to the patient.

For example, documentation regarding a patient who developed increased cervical soreness following a spinal manipulation should include the physical findings, results of any tests, the diagnosis and plan for future treatment. Documentation should not include your theory of the reasons for development of the patient's symptoms.

After you have disclosed the facts to the patient and/or family, document the information discussed; the date, time and place of the discussion; the names of those present; and your plans for subsequent treatment.

For example, "12/5/2025-3:00 p.m. Met with patient and his wife in my office and explained to them that the patient developed dizziness and neck stiffness after his cervical manipulation yesterday. I provided them with education regarding these post-treatment symptoms and explained that, as we discussed pre-treatment, this is a known association of cervical manipulation. I discussed treatment options including conservative measures and follow-up evaluation and the risks and benefits of each. The patient would like to continue conservative treatment prior to considering any further intervention."