Originally published March 2011 / Revised October 2016
While physicians strive to ensure complete and accurate documentation, deficiencies do exist. Inadequate documentation impacts patient care and outcomes, and can compromise a physician’s defence in medical-legal proceedings.
In this article
- Good documentation and the medical record: As the primary communication tool between physicians and other healthcare providers, the medical record is key to good patient care and is paramount to continuity of care. It is also a legal document that must meet specific legal and regulatory requirements and is vital to a physician’s defence if care is later questioned. Read more...
- Discharge summaries: Discharge summaries need to be timely, complete and accurate. Read more...
- Official notes and medical certificates: Official notes, such as for absence from jury duty, should be based on the physician's assessment of the patient. Read more...
Good documentation and the medical record
Good documentation in the medical record is accurate, objective and completed at the time of contact (contemporaneous). This means that complete and correct information is recorded, and the information is factual. Documentation that is contemporaneous is generally viewed as more accurate than recollections made by either physician or patient at a later date.
The physician's thought process is demonstrated through good documentation. The symptoms, physical findings and laboratory results on which a plan of care is based should be identified so that the plan is clear and logical. Good documentation describes what information is given to the patient and the patient's response. This includes notes about informed consent, the patient's questions, the physician's answers, and any information given to the patient about next steps or follow-up. Documentation needs to be legible and only recognized abbreviations should be used.
Inferences and assumptions should be avoided or at least indicated as such. Statements in the medical record should be supported and physicians should indicate when they are unsure. Good notes clearly document the facts of the situation and demonstrate thorough work. Inadequate notes are open to misinterpretation or are simply unhelpful either in providing care to the patient or in demonstrating what took place. Poor charting may be perceived as reflecting less than sufficient attention to detail and risks the conclusion that care was poor.
The importance of good documentation in medical records is a recurring theme in CMPA cases. In addition to supporting patient care, medical records are vital for the defence of physicians in the event that the care they provided is later questioned in a civil action or a complaint to a medical regulatory authority (College). Clinical notes are crucial when the estate of a deceased physician must defend that physician's care in a medical-legal proceeding.
In one CMPA case, the basis of the plaintiff's allegation was that the physician had not provided sufficient information to obtain informed consent prior to undertaking a procedure. The procedure resulted in a complication, which prompted the patient to take legal action against the physician. The CMPA assisted the physician. During his discussions with legal counsel, it was obvious the physician had a clear recollection of the information he had provided to the patient, though he had not documented any of it in the medical record.
The physician died before his evidence could be taken under oath. This meant there was no admissible evidence to refute the plaintiff's claim of lack of informed consent, and it was not possible to obtain support for the physician's care in this case. The physician's family was placed in the unenviable position of having to accept that his actions could not be defended and a settlement had to be made. Compensation was paid by the CMPA on behalf of the physician's estate. This unfortunate outcome might have been prevented had adequate documentation been available.
Documenting telephone and email advice
As in face-to-face visits, physicians providing advice by telephone must ensure consistent and full documentation in the medical record. During or immediately after a telephone conversation with a patient or family member, notes should be made and placed in the patient's medical record.
Physicians who communicate with patients by email should inform patients that the content of their emails in one form or another may be included in their medical record. The physician must consider whether it is desirable to include all patient-centred email verbatim or a summary of relevant clinical information.
Recoverable back-up copies of emails may remain on other computers or in cyberspace. This offers documentation of communication between patient and provider, allowing for more accurate reconstruction of interactions than the recollections of the physician and the patient can provide. Physicians should be aware that poorly constructed or carelessly worded emails may be used as evidence in a future investigation or proceeding when care is being questioned.
Modifying medical records
Modifications to medical records must be made carefully and according to applicable regulations and guidelines, such as those contained in College policies. Corrections or modifications should be made only to the physician's own entries and not to those of other healthcare professionals. Physicians should only make changes to ensure that the medical record is relevant and accurate. Changes should be dated and signed or authenticated electronically. It is important to preserve the original entry, and then to write, sign and date any additions or changes. Questions about making modifications to a medical record can be discussed with a CMPA physician advisor.
Electronic medical records
The need for good documentation extends naturally to electronic medical records. Physicians should use an electronic signature, such as a unique password or identification number, to identify information entered into the electronic record. The electronic signature links the document with the author.
The use of documentation shortcuts can be tempting when using electronic medical records. However, reusing previous documentation (cut and paste) can negatively affect the integrity of the medical record. Physicians do not want to carry forward information that may no longer be accurate or could contradict the patient's current status or situation.
To protect patient confidentiality, physicians should control access to their computer. They should take appropriate measures to close the electronic system when they are not using it. This helps avoid confidentiality breaches and will also prevent others from entering information that will be recorded under the physician's electronic signature.
Retaining medical records
Physicians should check the specific requirements in their province or territory for retaining medical records. While there are clear challenges to retaining records, especially paper-based documents located in physicians' offices, the CMPA recommends retaining records for at least 10 years from the date of the last entry, and for minors, at least 10 years beyond the age of majority. Of course, medical records should be secure and reasonable measures must be taken to protect patients' personal health information.
Legal and regulatory requirements
Medical records are legal documents and carry legal consequences as a result of how they are maintained and used. Medical records must contain information required by law and by College regulation. Physicians should be familiar with provincial or territorial legislation (including privacy legislation) and College regulations, regardless of whether or not the information is needed for clinical or other purposes, such as teaching or research. Physicians working in hospitals should also consult relevant hospital bylaws.
Nursing notes and other pertinent health care information
Important clinical information is documented by nurses and other healthcare providers who are part of the clinical team. Notes made by other healthcare professionals in the medical record provide information that can contribute to improved patient care. Physicians should review the documentation provided by other healthcare professionals as it may contain valuable information to help manage the patient's condition.
A good discharge summary may help prevent patient safety incidents and gives the subsequent treating physician the full medical picture to optimize continuity of patient care. An incomplete discharge summary, or one that arrives too late, leaves everyone at a disadvantage. The subsequent treating physician needs quick access to this useful and potentially life-saving information. When writing a discharge summary, physicians should ask themselves whether it includes all of the information needed to provide uninterrupted care. They should be aware of their hospitals' bylaws on record-keeping and that failure to comply with them could affect privileges and result in medical-legal difficulties.
At a system level, better physician documentation will improve the quality of hospital medical records. This will ensure better quality data is available to clinicians, healthcare planners, researchers, and decision-makers.
Official notes and medical certificates
Physician notes and medical certificates should be factual and objective, containing accurate statements based on current clinical information. They should indicate whether they are based on subjective history provided by the patient. Physicians should obtain the patient's consent prior to providing personal information to a third party and should not disclose more information than is covered by the consent.
For more information
Further information on documentation and medical records can be found on the CMPA website. CMPA members with specific documentation concerns are encouraged to contact the Association for advice from a physician advisor.