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Professional Corner

Documentation on Trial: Nine Ways to Protect Your Agency

By Gary Bowers and Judy Adams

In today's environment, healthcare professionals are often overwhelmed with documentation requirements. Licensor and certification surveyors. Office of Inspector General staff, third-party payers, fraud and abuse inspectors, courtroom attorneys, and others seem to scrutinize healthcare documentation constantly. In short, documentation is always "on trial." These tips can help agencies protect themselves in this environment.

Document everything

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court. Earlier this year, a home care nurse was called to testify in a trial involving a medication she gave to her patient four years ago. During that time, she cared for hundreds of patients and provided thousands of visits. Without actual accurate documentation, it would have been difficult to recall exactly what happened four months ago, let alone four years ago. Fortunately, her documentation was very specific and was a large factor in the dismissal of the case.

1. Accurate Documentation

The closer the documentation is recorded to the actual event, the more reliable it is. Agency policies should define how soon after the visit the documentation must be recorded. Agencies that allow staff to document their activities at the end of the day when they are tired and in a hurry (or at the end of the week to "catch up" on documentation) risk ending up with inaccurate notes.

2. Factual Documentation

Agency staff should state the facts by using objective, not subjective, terms. Advise staff to record their senses (touch, feel, and smell), the patient's actual words, and use specific measurements.

3. Complete Documentation

Look to industry standards of practice to identify comprehensive documentation. Avoid the use of vague terms like "raw" wound, "healing well," "small," "moderate," or "large" amount of drainage, and use objective terms. For example, staff should document the specific length, width, and depth of the wound ("9x5x1 cm") or, for a small wound, compare it to a common object ("si/.e of a dime"). Drainage could be documented as "saturates 2 4x4s in a 24-hour period.

4. Abbreviations

Although abbreviations can reduce documentation time, agencies should not allow notes to turn into a foreign language that no one can interpret. Use only agency-approved abbreviations and conform them to generally accepted lists.

5. Unsolved Mysteries

Do not leave the reader guessing. Describe gaps in service-caused by missed visits or hospitalizations. Document communication with physicians or other clinicians related to new findings or changes in the patient's condition. Nearly every type of external audit compares the services documented with those ordered in the plan of care. Auditors always raise questions when the last note in a patient's file indicates that the nurse or therapist will visit in two days, yet, no visit occurs for a week or longer and the documentation contains no explanation of what happened. The reader is left trying to guess whether the patient was forgotten on the schedule, the clinician forgot to write a note, or the patient disappeared.

6. Criticism

Avoid criticizing other agency staff, the patient, and/or caregiver in your clinical documentation. One agency nurse wrote in the medical record that the physical therapist "really screwed up," and a home health social worker called her patient "obnoxious and belligerent" Patients in most states have the right to review their clinical records; therefore, staff must be careful about what they document. Performance information should be reported to the employee's supervisor and documented in the personnel record; incident reports should be documented according to agency policy, which is separate from the clinical record.

7. Corrections and Late Entries

Liquid paper corrections should be banned from all clinicians' offices. Despite years of reminders, this substance still appears on charts from time to time. Staff should simply draw a line through the incorrect entry and note their initials and the date. For late entries, always document the time and date of the late entry, add the entry in the first available space in the record, clearly identify it as a late entry, and cross-reference it to the original event.

8. Confidentiality

It is important to document any special directions by the patient related to release of medical information. For example, a patient might tell the admitting nurse that she does not want her daughter to have any information about her condition. Later, the patient may change her mind and tell another nurse to explain "everything" to the daughter. If the second nurse does not document this change, the patient could later claim that the nurse breached her confidentiality by talking with the daughter.

9. Coordination of Care

Documentation should reflect all attempts to contact the physician regarding changes in a patient's condition. Include the name of the physician notified, a brief summary of the reason for the call, and the physician's response.

Clinical notes frequently state the presence of changes in the patient's condition, such as elevated blood pressure or increased pain, but do not indicate that the physician was notified of these changes. In one case, a physical therapist noted that the patient's blood pressure continued to be elevated and even noted that the physician should be notified. However, the therapist never documented the fact that he contacted his supervisor, the nurse assigned to the patient, or the physician to inform them about the high blood pressure. The patient suffered a stroke the next day.


A medical record should be an organized and clearly written synopsis of a patient's course of care from admission through discharge. Like a photograph album, a medical record contains snapshots that depict the patient at different stages of his or her care.

With factual, complete, and timely documentation, the medical record paints the full picture for the reader. Without it, providers create risky situations that result in potential liability.

Reproduced with permission of the National Association for Home Care.

The following is a sample of an instrument designed to help you rate your organizations (and your own) performance with regard to key reporting risks. Although originally developed for use by the American Physical Therapy Association, it can be adapted to any healthcare professional. Answer each question "true" or "false," and, if you're not sure, select "false." Now, relax and be honest...

Each therapist's documentation must be consistent with his or her own practices; the documentation of all providers in a department or clinic must be consistent.

1. If you document in one style for your Medicare population, your documentation for private pay or pro bono work is consistent with that practice.

2. The clinic has established a standard charting practice, and the reporting of all therapists (including you) is consistent with all elements of this practice.

3. The majority of abbreviations that providers within your department use are industry standards, and for those abbreviations that are not, there is a key provided on each page of the record.

4. All providers within a facility or location use only the same accepted abbreviations.

5. If the method used is charting by exception, there is a way to demonstrate that things are done but not charted are consistently performed.

In general, more objective information in the record is better, assuming that everything included is factual and clearly understandable.

1.Review of a patient record 2 years after treatment has ended provides sufficient information to describe to a jury 1) the patient's condition, 2) what was done, 3) why it was done, and 4) the results.

In all reporting, especially electronic, confidentiality must be maintained and modifications in the record must be fully explained.

Confidentiality Consciousness *

1. All employees are taught the importance of confidentiality and how to protect the confidentiality of the information with which they work.

2. All employees know how to properly handle a fax transmission of confidential information and what to do if it is misdirected.

Security Check: Storage Arrangements for Confidential Information on Paper*

1. All record/information storage areas that are not continuously supervised are secured access areas.

2. All security procedures are closely followed by all staff (eg, doors are locked when areas are unoccupied).

Changes in the record

1. If you are using handwritten documentation, any corrections in the record have a line drawn through the incorrect entry, and that line is dated and signed by the provider.

2. If you are using handwritten documentation, and there is a need for a late entry, the notes are not rewritten; rather, the entry is placed in an appropriately dated location in the chart for when it was written, and a rationale is provided for the late entry. The late entry and rationale are signed and dated by the provider.

3. If you are using electronic documentation, all corrections in the record clearly indicate the original wording of the note and the correction and include the date and authentication of the provider.

4. If you are using electronic documentation, late entries are noted as late entries, a rationale is provided for the late entry, and it is authenticated and dated by the provider.

Adapted from Abein, S. H., "Reporting Risk Check-Up," PT Magazine,

1997, vol. 5, no. 10, pp.38-42 with permission of the American Physical Therapy Association.


Count up all the questions to which you answered "true" and divide that number by 14.

If your score is 82% or above, you are well on your way to having documentation that is as defensible as possible. Remember, however, that any question answered "false" indicates a potential risk to you and/or your organization.

Review the questions to which you answered "false" and consider modifying your current reporting to protect yourself more completely in the event of a claim. If you are successful, the prosecuting attorney who serves you notice may not pursue the case after discovery. Defensible documentation can make that much difference.

The complete Risk Check-Up can be found on the APTA Web page.

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Last modified: January 26, 2013