5 CYA Charting Tips from a Malpractice Attorney

Recently we had a panel of attorneys share advice for nurse practitioners related to medical malpractice. As NPs, medical malpractice is something we must be aware of. We’re all human and we all make mistakes. Even those of us who practice error-free are bound to have a patient with a negative health outcome from time to time given the undeniable fact that health naturally decompensates over the course of a lifetime.

Wether you work in primary care, a specialty clinic or in the inpatient hospital setting, as a nurse practitioner you must practice with an awareness of these realities. Taking proactive steps to mitigate a medical malpractice lawsuit and protect your license no matter how good you are at your job is essential. Documentation is one of the keys to protecting yourself from liability. Here are five documentation tips from our attorney panel.

1. Know Your EMR Layout

Have you ever printed out a completed patient chart? If not, stop what you’re doing. Go straight to your EMR and print the chart for the last patient you saw. Does your entry look as you intended? Are there extraneous fields you weren’t aware of or any that appear incomplete? Are entires showing for staff or other colleagues such as vital signs entered by a nurse that you were unaware of?

Often times charts don’t look the same in their printed or ‘reader’ form as they do when we as nurse practitioners enter data into the EMR. If a patient encounter is ever called into question, however, the printed or ‘reader’ form of the document is what will be presented as evidence. Make sure that you know how the various fields in your EMR system appear in their completed format so your patient record comes across clearly and accurately.

2. Don’t Trust Your Colleagues

Double check each and every entry that appears in a patient chart. Inconsistencies and typos in line items like vital signs and social/medical histories are some of the most common errors in documentation. And, these are items that medical assistants and nurses are likely entering into documentation. These errors can be as simple as clicking “denies” for living arrangement. Really, the patient has no living arrangement? While errors like this seem inconsequential, they set a track record of sloppiness and carelessness in court.

From a legal standpoint, “someone else put it in my chart” is not an excuse. One inconsistency in a patient’s chart isn’t good. Two inconsistencies, contraindications or errors are enough to call the entire document’s accuracy into question. Make sure you are thorough in proofreading all documentation.

3. Name Helpers

Did a colleague or coworker assist in the care of your patient? If so, name them in the chart. This gives a record to fall back on if your decision making or level of care are ever called into question. This might mean naming the supervising physician you asked a question of and documenting the response. This might mean naming the nurse who chaperoned you during a sensitive patient exam. Or, it could mean naming the radiologist who read a diagnostic imaging record. Whatever the case, document the names and positions of the team members directly involved in the care of your patient.

4. Be Objective and Respectful 

In my own work as a nurse practitioner, I often see nurses enter a patient’s chief complaint in quotes. There’s nothing inherently wrong with this, except that I see quotations used almost exclusively in somewhat of a mocking form, for example when a patient uses poor grammar to express their situation. How would what you documented sound read aloud to a jury?

Any and all written or recorded correspondence can be reviewed as part of a medical malpractice lawsuit. Whether via text message, email, on a patient’s chart or in a chatting forum, correspondence about patient care must, must, must, be kept objective, respectful and professional. If you wouldn’t want your conversation read aloud in a court of law, don’t write it down. And, keep all communication about patients within your practice’s internal systems. You don’t want personal emails or texts coming into play in a lawsuit.

5. Document What’s Next

Whenever you see a patient, you should give guidance as to what’s next. Are there any home care instructions the patient needs to be aware of? What signs or symptoms might develop that signal there’s an urgent or emergent complication? Does the patient need to be referred to another provider?

At the end of each of my charts, I conclude with a line stating “Discussed with patient follow-up and return precautions”. Depending on the patient’s specific diagnosis and its severity I may or may not elaborate. Take the time to document the care plan and follow-up requirements for your patient so it doesn’t look like you’ve left them hanging.

A big ‘thank you’ to our attorney panel for filling us in on malpractice mistakes they see in practice and how to protect ourselves as nurse practitioners from legal missteps.

You Might Also Like: How Many Nurse Practitioners Can a Physician Supervise?