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The mantra that has long conjoined malpractice and patient safety is that “good practice is defensible, especially if it’s documented.” The flip side of that axiom is, of course, “if it’s not documented, then it didn't happen.”

Documentation is boring to read about, dreary to think about, and tedious to do—understood. But the reality is that, if you practice medicine, odds are you will be named in a malpractice claim or suit at least once in your career. And, while you can never be sure which patient encounter will lead to a malpractice claim, you can be certain your record of the encounter that led to a lawsuit will be crucial to your case. Physicians who pay too little attention to documentation increase both their risk of being sued for substandard care and their risk of an unfavorable case outcome.


Documentation as a Medical Malpractice Risk
  All CBS* cases Cases with 
inadequate documentation** 
as a contributing factor
Cases closed 
9,270 2,351
Cases closed with payment 40% 52%
Average payment $472,000 $695,000


*Comparative Benchmarking System, CRICO's medical malpractice database 
**Including clinical findings, clinical rationale, informed consent, and facts about the patient


Good documentation is not just a good defense, it’s how individual clinicians remember and how multiple clinicians communicate about patients they jointly care for. Diagnosis or treatment based on an incomplete record places the patient at unnecessary risk for harm and all members of the care team at risk for an allegation of malpractice. A physician forced to rely on his or her memory to fill in gaps or reconcile discrepancies in the medical record plays poorly in front of a malpractice jury.

Better documentation need not be more documentation. Short is okay as long as it completes the picture of the patient’s relevant history (complaints, diagnoses, treatments, screenings, etc.) and updates the care processes and plans related to any unresolved health issues. The patient's record should be decipherable by any subsequent clinician perusing it: obtuse or ambiguous abbreviations, acronyms, lab values, etc. that create the opportunity for misreading invite misunderstanding. Misunderstanding the record invites errors of omission and commission which, in turn, can be perpetuated until the patient has suffered unnecessarily. Documentation policies designed to limit unclear terminology are reliant on universal compliance.

Best practice policies aimed at documentation must now also consider access by a new reader: the patient. Experience with open notes is limited, but if the genie is out of the bottle, providers accustomed to writing “closed” notes may find the need to change some bad habits. If that results in a better record for all future readers, that will be both good practice and a good defense if the care is challenged.

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