Responsible Documentation of Patient Care: Avoiding Legal Risk Part II
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Methods of Documentation
Affirmative Duty Documentation:
- Complications and emergencies requiring management by the health care team, if one exists.
- Timely and appropriate action of the care team.
- Identification of personnel contacted, their title, data reported, changes in patient status, what was requested, and outcome.
Problem Oriented Documentation:
- Care team creates a problem list
Narrative Documentation:
- The ongoing patient assessment, data coming in, interventions undertaken, and the patient’s response.
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Documentation by Exception:
- Only significant or abnormal findings
Flow Sheet:
- Documents continuous or specific aspects of care.
Documentation of Communications
In brain-injured baby cases, the statute of limitation for initiating a negligence lawsuit can be as long as 20 years, depending on individual States’ statutes. After this much time, how much can the average provider recall about care involving an injured child? If not carefully documented at the time, it is likely that you will not recall communications that you had with the team, or even much about the patient. If your documentation was vague, then, you will certainly not recall, with particularity, the content of communications in the record. In this situation, you may be called to trial with multiple co-defendants, all with differing and conflicting recollections. You can expect to remain a defendant throughout the proceedings, even if your contact with the plaintiff and family was brief.
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At all times, when documenting a patient’s status, you should enter all significant facts and contacts. “Interviewed pt status with doctor” is grossly insufficient. To the best of your capabilities, you must document “what was said”. This includes details of conversations and discussions of assessment and plan. Re-creation of important conversations many years later is nearly impossible. This important documentation not only applies to patient condition, but to conversations with parents, colleagues, and family members and ensures accurate re-creation of important conversations years later. Do not leave it to trial or defense attorneys to insinuate the content of a communication for lack of a detailed note in the record. Attorneys are known to embellish an insufficient record to the jury. Lacking evidence to the contrary, they can make it up.
Modes of Communication
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You are expected to use reasonable judgment regarding how detailed your documentation becomes based on how critical the patient’s situation is. No need to write an essay on an order for a stool softener.
In regard to phone conversations, recording, only, that the call occurred is insufficient. You must document the important points of the conversation as best you can. For instance, you will document the individual who initiated the call, the purpose of the call, and its subject matter. You are also required to document an assessment and plan which results from the communication.
With text communication, document it and save it. For third party indirect communication, identify the individual. Do not record “doc” or “cnm” or “nnp”. Document their names. Strive to be as detailed as you can be. Document what was said significant to the situation, patient condition, your actions/response, and what you may be requesting. The time of your recorded communications should establish the interval between your assessment of a situation and the time you consulted. To the best of your ability, record everything related to your patients care.
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Remain objective and factual. Document what your patient is reporting to you, what you assess from the fetal monitor tracing or electronic assessments, and the plan that you formulate. Avoid he-said/she-said. Your contemporaneous documentation of the content of a conversation will have more credibility with a jury than vague recollections years later. Again, be detailed as possible in the context of the situation. Naturally, you may not be able to document situations and actions taken as they are happening. Do your best to record on any available surface (e.g. your scrubs, bed sheets, glove wrappers) if you can. Finally, involvement in critical situations with bad outcomes will likely land you in litigation world. However, if your luck happens to run out, even the most normal circumstances of care can, over decades, evolve into a medical malpractice lawsuit.
Identify Barriers To Communication
Although it may feel overwhelming, it is important to identify, consider, and mitigate barriers to communication. For instance, during care are you having to utilize a translator phone? Take note of cultural, intellectual or psychological factors that may interfere with communication. Barriers such as these will be examined in litigation so it is in your best interest to make a brief note of them and what you are doing about it. If there are significant barriers, you will be examined at trial on your recognition of them at the time of care, what they were, and what you did about them (diagrams, translator phone, another caregiver who is fluent in your patient’s language, help from family members, etc.).
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Names of individuals that assisted you with communication should also be noted in the record. These recommendations may seem excessive, but they can be your key to dismissal from a malpractice lawsuit. The more control you have over the facts of your care, and any future evidence filed against you, the better your chances for dismissal from a negligence case.
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© 2025 Martha Merrill-Hall