Whether physicians use the pen for documentation or have moved on to electronic charting, best practices for reducing medical liability risk are similar for both methods.
One of the most common techniques used for documentation is the SOAP format. The acronym serves as an easy reminder for what information should be gathered and documented.
S – Subjective data: The patient’s description of the symptoms or condition, the complaints of the patient.
O – Objective findings: The description of findings or observations about the patient, the history and exam.
A – Assessment: A description of the physician’s assessment of the subjective complaints and objective findings.
P– Plan: A physician’s blueprint for current and future treatment plans.
All entries should be signed and dated (either by pen or electronically) and made contemporaneously with the events they describe.
Safely charting litigious waters
At times, physicians may differ from each other in their recommendations for treating a patient. However, for both paper and electronic documentation, it is imperative that the patient’s medical chart not be the place to air any differences of opinion.
Also be sure that notes are objective. The record should reflect only information that is factual at the time of entry.
Correcting medical records
Correcting medical records can have devastating medical liability consequences if not done correctly. Physicians should only correct errors or omissions during the course of medical treatment.
For the electronic medical record, physicians must preserve the integrity of the record.
The original entry should be viewable.
Every addition, deletion or amendment must be automatically dated and timed.
- The person making the change must be documented.
Legally, the electronic medical record is considered irrelevant unless it can be proven in a court of law that the electronic medical record keeping system is tamper-proof.
Record retention, data protection and privacy
Physicians should follow the same record retention period for electronic documentation as paper documentation. The hardware necessary to retrieve old electronic records must be retained to access or reproduce those records.
For electronic documentation, physicians must have a fail-safe backup system in place. They must ensure that their contractual agreements with the vendor include who is responsible for performing backups. Also, in the event of system failure, the vendor contract needs to clearly indicate who is responsible for recovering the data.
Whether paper or electronic, physicians should always ensure privacy and security of patient information as required with HIPAA, including audit trails.
“Exploring Liability Issues in Computer Assisted Practice” is a new Risk Rewards brochure, available for download at www.ismie.com. Simply click on “Risk Rewards Resources,” scroll down to “Self Study Courses” and scroll down to the brochure.
Contact: Division of Risk Management, 800-782-4767 ext. 1627 or email@example.com