We all learned how to write notes in school. For many of us, school just covered the general contents of a chart such as the difference between subjective and objective, what is an HPI, and the difference between an ROS and physical exam. I used to work for a large scribing company and after years of scribing moved on to teach new recruits how to scribe. From my experiences there, I can tell you there is much more to medical documentation than this. When I was a scribe and now as a PA, I frequently see charts that do not cover their bases. I believe that we as clinicians sometimes lose focus on the whole point of charts.

It is important to remember that charts have three main purposes: medical, billing, and legal. Let’s start with the medical part. The next clinician that reads the chart should be able to understand what the the state of the patient was at that time and what you did to treat their condition. The billing part is straight forward. In order to be paid for the services rendered, you need to communicate what was done. The legal part, in my experience, is the most neglected. Remember medical charts are often used in court as evidence. If you ask yourself when you are charting if these three boxes have been check, then your charts will improve.

Here are some general tips. They are not all inclusive:

● Know your default templates well

○ For example, if you have atraumatic as part of your default head exam, remember to take it out when you have a patient with a head injury.

● Do not just focus on the negative

○ If you are prescribing a medication or ordering a test, you want to say that you discussed the risks AND benefits with the patient(or parent). Yes prescribing certain medication and ordering tests have risks and side effects but remember to discuss and document the danger of not treating the condition or getting the test. This shows clinical judgement.

● Remain professional

○ Watch your tone and word usage. Remember you are not the only one that will read your chart and if this does get brought into court you do not want your objectivty questioned.

● Continuity of care

○ This is a big topic that I am not going to get into here, but make sure your patient’s have follow-up after discharge. For example, if they tell you they have an appointment with their PCP on Monday, document it. Same if you make them an appointment.

● Clearly document any and all discharge instructions:

○ For example: patient instructions on how to treat their ailment, when to go to the ED, or when to follow up.

● Never falsify a record

○ This one is not only a crime, but it will destroy your credibility in court.

● Be careful with abbreviations

○ Only use your facilities approved abbreviations as they can lead to misunderstandings and mistakes.

● Be concise and direct

○ Do not be vague and left up to interpretation. Also do not be overly wordy, this can lead to more ammunition for the prosecuting party.

● ”If you didn’t document it, you didn’t do it:”

○ I am sure we have all heard this one before, but it is so important that I am going to reiterate it here. Document everything you do that is clinically relevant for the patient. Even as minor as looking over the med list provided by a patient. This not only serves you well from a legal stand point, but it also helps the billing department and any future clinician involved in their care.

● Patient nonompliance: document any evidence of this.

○ This is important for many reasons. Let’s say for instance you have a sick patient that has already been seen and given medicaitios, but did not take them. You may agree with the prior clinicians judgment and not do anything new for them other than have a conversation. To a future clinician looking at this case, this does not make any sense unless you are clear about the noncompliance.

● For any procedure

○ Be specific on what you did and document informed consent.

● Document who is in the room, if relevant

○ if if there was a parent or guardian in the room or if performing an exam needing a chaperone that there was one.

● Document your source

○ This is like citing your source in a paper. You need to say who said what in the HPI. This is especially important when the patient is not your main source of information.

● Others involved in the case

○ If another person involved in their care does not respond, make sure to document when the person was reached out to and what information was given.

References

Grady A. The Importance of Standard of Care and Documentation. Journal of Ethics | American Medical Association. https://journalofethics.ama-assn.org/article/importance-standard-care-and-documentation/2005-11. Published 2005. Accessed September 25, 2020.

Gutheil T. Fundamentals of Medical Record Documentation. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010959/. Published 2004. Accessed September 25, 2020.

Thehealthlawfirm.com. https://www.thehealthlawfirm.com/uploads/Ch-22%20Legal%20

Aspects%20of%20Documentation.pdf. Published 2008. Accessed September 25, 2020.

Maureen K. Medical Charting Rules to Protect Against Malpractice Claims. Maureenkroll.com. https://www.maureenkroll.com/articles/medical-charting-rules-to-keep-you-legally-safe.aspx. Accessed September 25, 2020.


About the Author:

Alexandra Schroeder PA-C

Alexandra has been an APPAA contributor since 2020. Alexandra is a recent graduate from Weill Cornell.