Most physicians document a patient encounter with the immediate needs of that patient in mind. The chart records what happened, communicates information to other members of the care team, and provides a history that can guide treatment going forward.

What is much harder to anticipate is how that same record may be read years later.

If a malpractice claim is eventually filed, the medical record becomes one of the most important sources of information about the care at issue. By then, memories may have faded, circumstances may be difficult to reconstruct, and a physician may be asked to explain decisions made during what was, at the time, an otherwise ordinary day of practice.

The chart often provides the clearest account of what happened and, just as importantly, why.

The Record Has to Speak for the Care

In medical malpractice litigation, attorneys and experts spend considerable time reviewing the medical record. They look at the patient's history, symptoms, test results, diagnoses, treatment plans, consultations, follow-up instructions, and the chronology of care.

But the record can also provide something less tangible: context.

Clinical decisions are rarely made in isolation. A physician may consider several possible diagnoses before determining that one is more likely than another. There may be a reason a particular test was ordered, a medication was changed, a consultation was requested, or a different course of treatment was not pursued.

When that reasoning is reflected in the chart, someone reviewing the case later has a much better opportunity to understand the physician's judgment at the time.

A record that simply states what was done may leave unanswered questions. A record that appropriately captures the clinical thinking behind the decision can tell a much more complete story.

Small Details Can Become Important Later

During a busy clinical day, certain details can seem routine: a conversation with a patient, an instruction to follow up, a discussion of treatment options, or a patient's decision not to pursue a recommendation.

If the patient's course later becomes the subject of litigation, those details may take on considerably more significance.

Was the patient advised to return if symptoms changed? Was a particular risk discussed? Was an abnormal result reviewed? Was a referral recommended? Did the patient decline testing or treatment?

Years later, a physician may genuinely remember the encounter but not every conversation surrounding it. That is not unusual, but the difficulty arises when an important detail cannot be confirmed by the record.

Contemporaneous documentation provides something memory cannot: a record created at or near the time the care was actually provided.

Documenting Judgment, Not Just Activity

Good documentation does not require recording every thought that crosses a physician's mind. Nor should a chart be written defensively in anticipation of a lawsuit.

It should, however, accurately reflect the care provided and the clinical reasoning that mattered.

If there were several reasonable treatment options, the record may note why one was selected. If a patient's symptoms changed, the chart should reflect how that change was evaluated. If a patient declined a recommendation, the discussion surrounding that decision may be important. If follow-up was necessary, the instructions and plan should be clear.

This kind of documentation is useful first and foremost for patient care. It also becomes invaluable if the physician is later asked to explain the decision-making process to an attorney, expert witness, or jury.

Electronic Records Create Their Own Considerations

Electronic health records have made documentation more efficient, but they have also introduced issues that can become important in litigation.

Templates, copied-forward information and pre-populated fields can save time, but they can also create inconsistencies when they do not accurately reflect a particular encounter. A seemingly minor discrepancy may later require an explanation.

Electronic systems also preserve information beyond what appears on the printed page. Depending on the system, metadata may show when a record was created, accessed, or modified. That can make the timing of documentation relevant as well as its content.

Accuracy matters more than volume. A lengthy note filled with information carried forward from previous visits is not necessarily more useful than a concise record that accurately captures the patient's condition, the physician's assessment and the reasoning behind the plan.

When a Claim Arises, Resist the Urge to “Fix” the Chart

Once a physician learns that an adverse outcome may result in a claim, it can be tempting to revisit the record and add details that seem important in retrospect.

However, that is exactly when physicians should be particularly careful. Records should never be altered to make the care appear more complete after the fact. Electronic systems may preserve a history of changes, and an alteration can create a credibility issue separate from the medical care itself.

There are legitimate circumstances in which a record may require a correction or addendum, but those changes should be handled transparently and in accordance with applicable policies. When litigation is anticipated or has already begun, physicians should speak with their counsel or professional liability carrier before making changes related to the care at issue.

A record does not have to be perfect for a case to be defensible, but it does need to be authentic.

Documentation Begins Long Before There Is a Case

One of the realities of medical malpractice litigation is that no physician knows which patient encounter may someday be examined in extraordinary detail.

The visit that later becomes the focus of a lawsuit may not have seemed unusual when it occurred. There may have been no reason to believe that the physician's recollection of a conversation, examination, or clinical decision would someday matter.

That is why strong documentation habits cannot begin after a claim is made.

A thoughtful medical record preserves the information that was available at the time, the care that was provided, and the judgment behind it. If questions arise months or years later, that record gives the physician and the defense team something far more reliable than hindsight.

At Kutner, Corrado & Friedrich, LLP, we know how important the medical record becomes once a physician is facing a malpractice claim. Long before a deposition is scheduled or a case reaches a courtroom, the documentation created during the course of patient care may already be helping to tell the story.

Disclaimer: The KCF News Room provides general information regarding medical malpractice litigation and related issues. It is not intended as legal advice for any particular matter.

Why Documentation Matters Long Before Litigation Begins