Since proper documentation of clinical interactions is critical for both patient safety and provider protection, physician notes in patient health records should meet certain standards. An article for the Journal of the American Health Information Management Association explains that while health records serve many purposes, their focus should be on “accurately telling the patient story.”
The article’s author, RN Tammy Combs, emphasizes that records providing a comprehensive view of each clinical encounter create the most accurate picture of a patient’s health. This is particularly important when a patient may rely on a variety of providers and healthcare professionals for care. “It would be detrimental to the patient if a provider only considered the care that was provided in one setting to guide their medical decision-making,” Combs writes.
To ensure that clinical documentation is considered “high quality,” Combs says that there are seven main characteristics to consider. Specifically, she notes, documentation must be:
- precise and
This type of high-quality documentation can also minimize liability exposure for physicians. For example, failure to properly document an after-hours telephone call can be problematic from both a patient safety perspective and a legal standpoint. As described in a previous MLMIC Insider post, if an undocumented telephone conversation becomes an issue in a lawsuit, the jury is less likely to believe the recollection of the physician, who receives a large number of calls on a daily basis.
MLMIC encourages insureds to explore our resources on the importance of properly documenting clinical interactions, including Insider posts on strategies to mitigate risk related to documentation, communication and follow-up and documentation considerations for EHR open notes.