Medical Record Documentation: Paint The Clinical Picture with Complete and Accurate Documentation November 4, 2024 Practice Management, RCMA/CMA, Resources, Risk Management Business Partner, Medical Record Documentation, ProAssurance, RCMA, Resources, Risk Management 0 This informative article is provided by ProAssurance Download Article By Tracy Valentine, RN, MHA, JD, CPHRM Introduction Medical record documentation errors continue to play a significant role in medical malpractice claims. Incomplete and inaccurate documentation can lead to a variety of unintended consequences including delayed diagnosis or misdiagnosis, patient harm, and death, any of which can lead to medical malpractice claims. Documentation errors encompass missing or incorrect information in charts, notes, transcriptions, and other electronic health record (EHR)-related areas. Copy/forward and drop-down menu functions, the ability to easily document on the wrong patient or in the wrong location of a chart, and late entries that may appear concurrent are all documentation issues that can cause patient injuries and/or impact the defense of a lawsuit. Certain aspects of the medical documentation process may invite behaviors that contribute to errors and inappropriate notations, increasing the likelihood of later liability. In addition to ensuring accurate, objective documentation and edits, and effectively addressing late entries, physicians should refrain from assigning blame or negatively characterizing other physicians. They should likewise avoid making derogatory comments about patients in their documentation. The medical record is a legal document and often the most critical piece of evidence in medical malpractice defense. Unfortunately, medical students, residents, and physicians get very little education on proper documentation during their training.1,2 Drop-Down Menu Selection Errors The use of drop-down menus for medication ordering, while convenient and allowing for quick order entry, can also lead to error if the wrong selection is made. Hastily selecting the wrong dosage can lead to catastrophic outcomes. In the following case, a medical error that occurred in the post-anesthesia care unit (PACU) led to permanent injury of a young patient. Case Study A 45-year-old female presented to the hospital for a scheduled laparoscopic hysterectomy. The patient had a large body habitus necessitating conversion to open surgery. The patient tolerated surgery well and was transferred to the PACU. While in the PACU, the patient began to experience increased pain to her surgical site and requested pain medication. The nurse administered the physician’s ordered dose of hydromorphone 4 milligrams (mg) intravenously (IV). Shortly after the administration of the hydromorphone, the patient began to have difficulty breathing, and her blood pressure dropped to 82/40. The patient became unresponsive to verbal and tactile stimulation, suffered respiratory arrest, and coded. Chest compressions were performed followed by the administration of naloxone and epinephrine. Intubation was attempted multiple times, unsuccessfully. Eventually the patient's oxygen saturation returned to baseline. Unfortunately, she suffered an anoxic brain injury during this event that left her with neurocognitive symptoms including episodic memory loss, difficulty with speech, and the inability to perform activities of daily living (ADLs). Upon investigation it was determined the physician, who routinely ordered a 1 mg IV dose of hydromorphone for postoperative pain control, mistakenly chose a 4 mg IV dose from the drop-down menu. The patient and her husband sued the physician and the hospital. Review of the EHR audit trail clearly indicated who made the order and when the order for the hydromorphone was placed. Ultimately, the case was settled. Discussion Though most EHRs utilize drop-down menus for a variety of orders and entries, it is important to be mindful of what is being entered into the record. Here the physician should have paid closer attention to the dosage selected in the dropdown. There may have also been an opportunity for the PACU nurse to question the order, notify the physician of her concern, and obtain clarification. Both defense and plaintiff experts commented that the usual IV dose of hydromorphone is 0.2 to 1 mg given slowly over two to three minutes. Further complicating matters is the associated boxed warning carried by hydromorphone alerting prescribers of the risk of medication errors and life-threatening respiratory depression. Risk Reduction Strategies Consider the following risk reduction strategies to help improve patient safety: Physicians Review medication entries for completeness and accuracy, paying close attention to selections made from drop-down menus. Nurses Always clarify orders if there is a question about their accuracy before administering medications. Administrators Adopt EHR functionalities that alert prescribers to potential medication dosing errors, associated boxed warnings, and drug interactions. Establish an environment that prevents interruptions or distractions for physicians during order entry to minimize errors. Work collaboratively with clinician users and EHR vendors to optimize functionality and help ensure drop-down menu item choices are accurate and consistent with the expected use. If certain medication dosages are rarely used or unsafe, remove these from drop-down menus. Conclusion Medical documentation is a critical double-edged sword. Not only does it remain at the heart of many medical malpractice cases, but it is also sometimes the only evidence to help protect a provider from liability during a lawsuit. Electronic medical records have opened new potential gaps in proper documentation, and providers must be as diligent as ever in their medical record-keeping practices to ensure their documentation is comprehensive, complete, and done in a timely manner. Endnotes 1. Jason Lai and David Tillman, “Curriculum to Develop Documentation Proficiency Among Medical Students in an Emergency Medicine Clerkship,” MedEdPORTAL 17 (November 2021):11194. https://doi.org/10.15766/mep_2374-8265.11194. 2. Emily Klatt et al., “Note to Self: Principles for Better Documentation,” NEJM Resident 360, April 20, 2022, https://resident360.nejm.org/content-items/note-to-self-principles-for-better-documentation-3. The information provided in this article offers risk management strategies and resource links. Guidance and recommendations contained in this article are not intended to determine the standard of care, but are provided as risk management advice only. The ultimate judgment regarding the propriety of any method of care must be made by the healthcare professional. The information does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about this topic should be directed to an attorney. Comments are closed.
