"Although chart completion may seem like a chore that can be put off until later, this decision can backfire," cautions Kenton H. Steele, Esq.
The importance of timely and comprehensive documentation is a frequent topic of conversation in health care. It is easy to understand how an incomplete record of a patient’s conditions and medications can cause complications for a subsequent care provider. However, health care professionals may be less familiar with the legal consequences that can result from even a brief delay in completing a thorough record of a patient encounter.
Medical documentation creates a record of all information about a patient that a future care provider may need to make decisions about treatment. Accurate documentation is an essential step to ensuring the standard of care is met. A failure to document can cause adverse outcomes, which can in turn lead to malpractice claims. However, even when a failure to timely and thoroughly document a patient encounter does not directly affect subsequent care, it can still lead to a time-consuming and costly lawsuit.
A recent case involving a patient who went to an emergency department (ED) with a complaint of back pain is a prime example. The patient arrived at his local ED and explained that earlier in the day he had strained his back when he slammed on his brakes to avoid a low-speed car crash. After evaluation, the patient was given pain medication, which relieved the pain quickly. The patient’s vitals and a brief description of the encounter were charted shortly after the patient was sent home with instructions to follow up with his primary care doctor.
The ED doctor, in keeping with his typical practice, planned to use his handwritten notes to add a more detailed description of the encounter to the chart the following day. Unfortunately, a short while later the patient returned to the same hospital via ambulance after his wife found him unresponsive. Efforts to revive the patient were unsuccessful. It was subsequently determined that the patient’s back pain and death were caused by a dissecting thoracic aneurysm rather than muscle spasms from the car crash.
When the ED doctor who had originally seen the patient returned to the hospital for his shift the following day, he learned what had happened. The doctor then added the late entry narrative of the encounter to the chart, but a much different version of the encounter appeared. The doctor noted that he had been concerned about a possible thoracic aneurysm and had essentially begged the patient to undergo testing, which would have likely revealed the patient’s true condition. According to the doctor’s late entry, the patient’s concern about paying an insurance deductible and anxiety about being in the hospital made the patient insistent that he be released as soon as possible without any diagnostic testing.
When a lawsuit was filed by the patient’s wife, based on the alleged negligent failure to diagnose the aneurysm, the timing of the doctor’s late entry was uncovered. The late entry, combined with the wife’s testimony that her husband never had anxiety about hospitals and would not have been concerned about an insurance deductible, converted a standard failure to diagnose claim into a far more complicated claim. The new allegation was that the ED doctor had fabricated the additional details of the encounter to avoid liability for the patient’s death. The allegation of improper bolstering of the medical record created a very real possibility that the patient’s wife would be awarded millions of dollars in punitive damages. This led to the patient’s wife credibly seeking well over $10 million from the doctor and the hospital. After years of litigation, the case ended with a multimillion-dollar settlement.
Although the doctor documented the encounter, the untimeliness of the entry—and its possibly fabricated information—created more liability than if the record had not been updated. When he learned of the patient’s outcome, the ED doctor likely would have been better served by consulting with his hospital’s risk management team before making any change to the patient’s medical record. If this had been done, the outcome of the case likely would have been significantly different.
In today’s fast-paced environment, a practitioner’s time and attention are precious resources that should be put to best use. Although chart completion may seem like a chore that can be put off until later, this decision can backfire. Delaying the completion of a chart can result in spending weeks in a courtroom if a lawsuit arises. Even when the demands of providing patient care require that documentation be delayed, providers should be mindful when completing after-the-fact charting. When in doubt, consulting with risk managers can reduce the possibility of an allegation of improper modification of a patient’s records.