Of all the issues in risk management, none produce quite the same eye-rolling and sighing among physicians and medical staff as the topic of documentation.

Healthcare professionals who arrive at educational sessions and find documentation on the agenda tend to secretly—and sometimes not so secretly—wish they had called in sick.

That’s unfortunate, because documentation is a cornerstone of medical care. In order to treat patients effectively, healthcare providers must hear their story, both from them and their family/support network. Then they must transmit that story to other involved parties. Good documentation is the way to communicate the story efficiently and accurately.

A thorough assessment of any patient begins with the patient’s or family’s description of what is going on. The plan of care—with its goals, strategies, time frame and measures of success—flows from this assessment.

For all members of the healthcare team to be able to do their part, they need to have access to the information generated through the assessment and in the plan of care.

Most physicians may be convinced that their documentation is comprehensive and complete, but closed-claims reviews across medical specialties demonstrate otherwise. They show that poor, incomplete documentation is present as a risk issue in at least 50% of medical malpractice cases.

Indeed, despite policies and procedures; checklists and tickler files; hospital, payer and government requirements; continuing education; and just plain nagging, medical records—which are the determining factor in 80% to 85% of all medmal lawsuits—can be woefully inadequate witnesses to the medical care provided.

In reviewing SCPIE’s closed claims files, the following problems are frequently evident:

• Altered documentation
• Incomplete or missing documentation
• Allergy history not documented
• Lack of documentation of phone advice
• Missing progress notes and lab reports
• Illegible notes
• Incomplete informed consent
• Informed refusal not documented
• Patient education not documented.

Lack of good documentation not only reflects less-than-optimal patient care, it is also a prime factor in liability loss. In the absence of complete, consistent and comprehensible documentation, how can healthcare professionals possibly prove what they did, why they did it and what results they expected to achieve?

By focusing on documentation, are we caring more about paperwork than patient care? Not at all. Documentation—caring for the medical record—is patient care!