The Role of Documentation in Diagnosis-Related Malpractice Cases
Laura M. Cascella, MA, CPHRM
Allegations associated with diagnostic errors — i.e., wrong diagnoses, delayed diagnoses, and missed diagnoses — are a top cause of malpractice lawsuits. Various risk factors can lead to diagnostic errors, including issues related to documentation of clinical care.
MedPro Group’s closed claims data from 2015 to 2024 show that documentation issues occur in 1 in 5 diagnosis-related cases. These issues generally fall into three overarching categories: (1) insufficient/lack of documentation, (2) content decisions, and (3) mechanics.
Documentation as a Contributing Factor in Diagnosis-Related Malpractice Cases
When it comes to defending malpractice claims, accurate and thorough documentation of the provision of clinical care is crucial. Thus, understanding the types of documentation missteps that contribute to diagnostic errors can help healthcare providers assess their current processes and adjust as necessary to reduce liability exposure.
- Insufficient/lack of documentation. Among the categories represented in the previous graph, insufficient/lack of documentation dominates. Examples of situations that can lead to documentation deficits include:
- Missing documentation in the patient’s record (e.g., patient problem list, test results, consultations, referrals, signatures indicating review, or medication lists).
- Failure to document adequate details about the patient encounter, such as important clinical findings. This issue can be particularly problematic in electronic health records (EHRs) due to overreliance on check boxes and form fields.
- Failure to document, or lack of documentation regarding, the informed consent process or patients’ refusal of care.
- Failure to document, or lack of documentation regarding, the clinical rationale for treatment decisions.
- Failure to document, or lack of documentation regarding, adverse outcomes.
- Failure to document attempts to follow up with a patient about care or test results.
- Failure of healthcare providers to document that they have been involved in a patient’s care.
- Content decisions. Content-related concerns include problems such as inconsistent documentation (in conflict with a provider’s own documentation or other providers’ documentation), altered documentation (which might suggest an attempt to cover up mistakes), opinions stated as medical facts, inappropriate comments or speculation (e.g., subjective vs. objective information), the proliferation of inaccurate information as a result of the copy/paste function in EHRs, or general inconsistencies in documentation patterns across records.
- Mechanics. The mechanics category refers to inaccurate documentation within a factual setting. Examples include inaccuracies in transcribing or writing orders, illegibility (including the use of nonstandard abbreviations, shorthand, or “text talk”), delays in documenting, and failure to use an appropriate method for correcting documentation errors and making amendments.
Documentation Risk Tips
Because of documentation’s essential role in healthcare, following best practices and standards is crucial for providing high-quality care and minimizing risks. The following strategies can help ensure adequate and appropriate documentation:
- Ensure your organization’s documentation policies require providers to document:
- Sufficient details related to the patient’s history and physical exam. This documentation will help support continuity of care and comparison of findings from previous visits.
- Patient adherence to treatment plans and appointments, including missed and canceled appointments and attempts to follow up with the patient. Providers should be careful to remain objective in their documentation and avoid editorializing.
- Treatment plan changes, such as receipt of diagnostic results, follow-up with the patient, patient response, electronic messages, and phone conversations (including after-hours calls).
- The use of qualified interpreters or auxiliary aids to address language barriers or other communication barriers.
- Consultations and referrals, including conversations with the consulting provider, agreed-upon consulting arrangements, and receipt and review of consultation reports.
- Patient education, including written and verbal advice, recommendations, and educational materials — as well as tactics to ensure patient understanding of the information (e.g., use of the teach-back method).
- Establish appropriate timeframes for completion of documentation following patient encounters.
- Consider whether documentation supports clinical judgment and decision-making, and whether it clearly identifies how a particular diagnosis was determined.
- Do not include incident reports or criticism of other providers in patient records. Root cause analysis of errors and near-misses should be documented as part of the practice’s risk management and quality improvement efforts.
- Understand and educate staff about the appropriate methods for correcting or amending documentation.
- Ensure that documentation policies address issues unique to electronic documentation, such as the use of copy/paste, form fields, check boxes, etc.
- Develop policies related to using medical scribes (if applicable), including the expectation that healthcare providers review all scribe-generated documentation to ensure accuracy and completeness and provide a signature and date/time to confirm review and approval.
For more helpful documentation strategies, see MedPro’s Documentation Essentials and Electronic Documentation checklists.
