A nurse wrote this week saying she always heard that “If it wasn’t documented it wasn’t done”, but at a program she heard a lawyer assert that this concept was “antiquated” and that documentation was less important than it used to be. A physician recently told me that a defense lawyer advised his group not to document details so it was harder to
prove if he screwed up.
Is That Good Advice?
First let me say that you can always attempt to prove something that was not documented, but it is a lot harder because it wasn’t documented. It is also true that if you plan on screwing up on a case, I guess you can also plan to hide the evidence. Otherwise, this is terrible advice.
Just How Important Is Your Documentation?
All you have to do is to think about all of the reasons other than malpractice defense that we document. Patient safety and continuity of care are two biggies that become very important if you are the patient or their family, and I can personally attest to two times hospitals almost killed me — one because of poor documentation and one because no one read the documentation that was there.
Another Big One — Getting Paid
The hospital, for instance, pays for drugs that are given to the patient. If nursing or anesthesia doesn’t document giving the drugs, the hospital still pays out the money for the drugs, but nothing is paid for. Sooner or later, the hospital has to start laying off people. Similarly, if the doctor forgets to document and order the antibiotics within the proper time period for surgery, Medicare won’t pay.
Following along this line, Coders need the documentation to support their billing codes so the doctor and hospital get paid. And when OIG and RACK auditors come in, whether someone is going to jail or your office or hospital is paying millions of dollars in refunds and fines depends 99% on your documentation supports your billings in detail.
More Areas
When a physician or nurse goes before a professional board over patient care issues, most of the hearing will revolve around the medical record and every detail will be scrutinized by the hearing board, the expert witnesses, and the attorneys.
In your facility or office, accreditation surveyors will often review patient records to determine whether they comply with policies, procedures, and regulatory standards.
Your quality assurance efforts are data driven, and that data is only available from detailed medical records.
When CMS shows up for an EMTALA investigation they make it absolutely clear that documentation is essential to your proving you are in compliance.
… But you are probably getting my point.
So What About Malpractice Defense?
When it comes to defending yourself against a possible malpractice claim, detailed documentation is essential.
1. It is almost 100% of what you will remember about the episode of care when it comes up years later in court. If you did not document it, you will not remember it from the perhaps thousands of other patient care events that you have had since.
2. It is 100% of the factual basis from which your expert defense witness must base their opinions in the case.
3. It is 100% of the visual “hard evidence” that you have to show the Jury to back up your testimony.
4. And it is what the Jury typically falls back on to help resolve all of the conflicting evidence and lawyer arguments at trial.
A Documentation Surprise
According to some of the top Plaintiff’s malpractice attorneys in the country, an incomplete and unprofessional medical record is one of the main things they look for in the cases they take. A good record is much less likely to result in suit.
So Can We Forget About Detailed Documentation?
Much as nurses and doctors would love to cut their paperwork and documentation, there is nothing to suggest that is going to happen without horrible consequences.
In fact, defense attorneys are quite concerned that the documentation produced by electronic medical records is not adequately detailed and that cut-and-paste documentation produce errors. Some are already labeling them “indefensible”. The answer to that is more emphasis on documentation by the care providers.
So I Ask You–
Has your malpractice insurance company come out with a Risk Advisory telling you to stop detailed documentation? Until that happens, I don’t think you can label it “antiquated.”