Thank you for joining us for today's educational program, Documentation with a Jury in Mind. Content in this presentation is intended solely to provide general information concerning the developments in the area of risk management. It is not intended as legal or medical advice, nor does it offer or solicit for offers with respect to any insurance product. Legal or medical advice should be obtained from qualified legal counsel or other professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards. And listeners should consult their own insurance advisors for information pertinent to the purchase of any insurance product. This content may not be reproduced or redistributed in whole or in part without the prior written consent of Allied World. My name is Kara Staus, and I will be your speaker today. I am an Assistant Vice President in the Risk Management Group for AWACS Services Company, a member company of Allied World. I provide risk management consulting services to Allied World's Medical Professional Liability policyholders and insured psychiatrists, psychologists, psychiatric nurse practitioners, and physician assistants. I work directly with policyholders to develop individualized action plans to mitigate potential loss based on their unique exposures and risk management needs. Additionally, I assist these clients with ongoing medical educational programs, as well as policy and procedure review and development. Our objectives for today are going to be to describe how documentation is used for defense and litigation, explain basic documentation principles, identify the risks associated with documentation in the electronic health record, and lastly, to apply best practices for documentation in the medical record. So let's start off with an overview of the elements needed for claims against physicians. Most claims involve a claim for negligence, and in order for a plaintiff to prevail, they would have to prove the following, that a duty was owed through a doctor-patient relationship. Second, there was a breach in the standard of care, and then there was a causal relationship or a link to the alleged damages. Claims are brought when there is a real or perceived deviation from the standard of care. It's important to note that laws regarding the standard of care do vary from state to state and generally the standard of care isn't what an expert might have done, but rather whether or not the actions of the physician were similar and reasonable with the same degree of care and knowledge, which would be practiced under the same and similar circumstances. So a lot of words there, but essentially, you know, a psychiatrist practicing with the same degree of care and knowledge for the alleged claim, that would be what the standard of care would be. So it's important to note that psychiatrists are the least, I say, sued medical malpractice claims that we see in the industry, and this slide is going to review the common claims against psychiatrists. So let's take a look at these. Improper assessment of suicide or violent patients. So essentially, did you fail to assess someone who was at risk for suicide or violence? Did you document, you know, the assessment? Did you fail to recognize that someone was suicidal or homicidal or had a tendency towards violence? Failure to diagnose. Failure to diagnose in psychiatry can be difficult, and again, this is where the standard of care would apply, is using the methods that you would traditionally see in the diagnosis in psychiatry and following the standard of care for appropriate treatment. Improper treatment. So this may be classified as improper monitoring or even failure to monitor. Vicarious liability. So what exactly is vicarious liability? So if you have office staff that are working for you or other physicians or mental health providers, you are essentially responsible for the acts of your staff. Whether you are held legally responsible may be another issue. You also may find yourself in a supervisory role of another clinician and also provide professional direction of the care and treatment of the patients under the care of these clinicians. So it is important to know that in the legal doctrine, vicarious liability is also known as respondent superior. When that comes into play, basically what this means, in other words, is that the doctor is responsible for the acts of another provider. So it's not a defense for you to say that you were not aware of the events leading up to that claim. So it's important to note that when you're supervising, be aware of statutory requirements for the level of the practitioner you're supervising. Review their documentation for accuracy and appropriateness to the plan of care and understand your role. It's also important to review contracts for your role as a supervisor before agreeing to be the supervisor. And also note that APA has a tremendous resource and guidelines for supervisory collaborative and consultative relationships with non-physicians. Another claim that's common in psychiatry is prescribing. Prescribing such as, you know, the black box warnings on medication or the toxicity, monitoring and documenting the side effects. Again, having that informed consent conversation with the patient so that they understand the risks and benefits of the medication you're prescribing. Think through your documentation of the physical effects of the medication and take appropriate steps to monitor and manage these effects. Also documenting these effects. Failure to provide informed consent. Documentation of informed consent, knowing that it's not just a form, rather it's that conversation, as I just mentioned, of the risks and benefits really of the treatment that you're providing. To allow for appropriate dialogue between the patient and the physician so that there's an interaction and the ability to ask questions and understand. Abandonment. So each state addresses termination and abandonment differently. So it is important to understand what your state's regulation is regarding termination, such as notification timelines. It is important that you document any referrals, emergency coverage and medication management when it comes to discharge termination so that you avoid a claim for abandonment. And then there also are claims regarding HIPAA, so privacy, you know, breaches of release of records, boundary and ethical issues, and then patient rights in terms of civil commitment. So let's look at documentation in malpractice suits. Why is it so important? So keep in mind that even when allegations are groundless, the mere fact that you have been named in a lawsuit will likely add, you know, a lot of stress and anxiety to you. So it's important, you know, to take the steps to make sure that you understand exactly what's going on with the case. So documentation. Lawsuits may take several years to resolve, and it's ultimately vital to the defense of any complaint or lawsuit. So the good news is, is there's so many ways to reduce the risks of being sued and if sued, ways to defend yourself. And so the principal way is really through your documentation. When the medical record is complete and well-documented using best practices, it really becomes essential and vital to a solid defense. On the other hand, if things are not well-documented, it makes very defensible actions hard to defend. So now we're going to dive into some of the best practices in documentation and talk a little bit in further detail. So discovery. What is discovery of medical records in a malpractice claim? So plaintiff attorneys and experts will review medical records and look for potential gaps in the record. So first of all, the plaintiff attorney is going to request a complete copy of the patient's medical record, obviously with the patient's consent, and then they're going to scrutinize that record to find holes in the care and treatment provided. So essentially, the attorney is probably not going to be the one reviewing the record. They're going to obtain somebody in a similar specialty to review the record for them. What they're doing is they're looking for evidence of negligent care. They're looking to identify any information within the record that may challenge the credibility of those involved. So any provider that's documented in the record, they're looking to challenge that. They're going to be looking at the assessment of patient care and communication between you and the patient and communication between you and other providers. And they're also going to be looking at interventions or lack of interventions to address the patient issues. So defense counsel has identified documentation risks associated with malpractice suits, insufficient documentation. It goes without being said, if it wasn't written, it didn't happen. So not having enough documentation or clarity in the treatment plan is a potential gap. So the lack of details. Don't allow for a plaintiff counsel to fill in the gaps for you. Make sure that your documentation really tells a story of the patient's care from start to finish. Lack of documentation, simply not documenting. Not having documentation, again, is a gap. There could be missing elements that, again, you will allow a juror or an attorney to fill in the gaps. You don't want that to happen. You are the professional who was responsible for driving the care. You want the medical record to tell the story so that that individual knows exactly what the care and treatment was of the patient that you were treating. Inadequate or missing informed consent. We talked about the importance of the informed consent. Again, making sure that the patient consented to the treatment, making sure that there was a signature on the informed consent form, that they understood the risks and benefits of the treatment. A lot of times we have seen records that have the informed consent document placed in the record. However, it's not signed. So pay particular attention to having signed documentation within your record. And then remember, most attorneys are not physicians. So you can also assume that the jury will have limited clinical knowledge. And therefore, the documentation in that record should be able to tell the story and be easy to follow. Again, you don't want individuals to make assumptions of what you did or didn't do. And it goes without being said, never make changes to the record or delete anything to the record following an adverse event or a complaint or circumstances that could give rise to a claim or lawsuit, such as a patient complaint. So we're not saying that you can't do a addendum or a correction. And we'll get into that down a few slides down the road. But again, any alteration of a record affects the defensibility of a case. When signing claims, the medical record really is a legal document and it's the only evidence available years later. So keep in mind when claims turn into lawsuits and go through litigation, it could take on average three to five years, sometimes longer for a case to go to trial. And so again, the medical record is really going to be what's going to spark your memory in terms of the patient that you treated and the facts and details surrounding their care. It's again used to reconstruct the care provider and it's considered to be an accurate reflection of the care provided to the patient. So again, as we all know, dates and times of what you said, memories could easily fade. However, having that thorough and complete medical record really is going to spark the memory and have a clear depiction of the care and treatment that you provided to this individual. Medical records are going to be scrutinized in the event of litigation by both plaintiff and defense attorneys. And it does provide a consistent record for communication and continuity of care. So again, keep in mind that that record is served a purpose in healthcare from a communication standpoint, and then it also reflects your professional credibility. It speaks to the quality of care and it ensures an ongoing recognition and understanding of quality improvement efforts and the care, again, and treatment you provided to the patient. So we talked about a legal document. The medical record is the most important pieces of patient care, and it's also a legal document. It's a business record, and it should reflect accurate and contemporaneously reflection of the care and treatment provided to the patient for the duration of care. Understanding that this business record also reflects billing practices. It must comply with federal and state regulations, such as the Centers for Medicare and Medicaid, as it pertains to billing and other regulatory matters. In the event you work for an organization that has accreditation, that medical record does have and reflect accreditation standards. In the event there is a survey, medical records often get audited and surveyed. The Department of Public Health, as well as state-specific statutes, have regulations on medical record documentation. In order to comply with your professional practice standards, there are standards that are established with documentation, how often you should document and when you should document, and then complying with legal standards. So your practice policies and procedures or the facility that you work for might have policies and procedures as it relates to documentation. So what types of documentation are there? Not just the medical record that you're charting in, that the patient might have access to, but other documentation that might be used in the event of litigation or the event of any legal matter are office practice and policies. Practice policies are very important to maintaining compliance within your practice, and there may be times you have to leverage your practice policies to reinforce nonadherence, such as missed or canceled appointments. So it is important to keep your practice policies up to date and make sure you share those practice policies and procedures with your patients so they understand the expectations that you have as a provider. Consent for treatment. We talked about the consents, that thorough and complete consent process is essential in healthcare. So oftentimes when complaints related to care and treatment are alleged, the attorney looking to defend a case will look at whether or not that informed consent process was outlined and detailed, and most importantly signed by the patient or their designated representative. So it is important to have signatures on all documents within the medical record as it does reflect that they've acknowledged an understanding by the patient. So progress and treatment notes. Obviously that's an essential component to the medical record. While there's no set standard for timeliness of documentation when it should be completed, the Centers for Medicare and Medicaid do state that documentation should be within a record within 48 hours from the time they were seen. So it is recommended as best practice to document timely as that documentation does serve as a communication tool amongst providers. So in the event another provider has to review the documentation, you can ensure that the provider reviewing the notes is reading the most up-to-date and accurate patient information. It's important to note that any communication which discusses patient care needs to be added to the medical record. So for example, any emails, texting, and telephone messages. This is why we make a recommendation that those types of communication with patients should be limited to really very basic information such as the scheduling and canceling of appointments. In the event you have patients that prefer communication by email or texting, it is important to have the proper consent, but recognize those types of communications, again, if there is anything that states patient care related directions, whether I've sent a script to the pharmacy or, you know, in follow-up to the appointment that we had, anything regarding patient care, it needs to be reflected in the medical record. So again, it's best to limit these types of communication to avoid any omissions in the medical record. Consultations with other providers should be well documented in the record. It's a justification that the consultation did occur, and then any outcome and follow-up, if appropriate, should be documented. In the event you receive medical records from another provider as part of the plan of care for your review, and you house them within your medical record, keep in mind that this now becomes a part of your complete medical record, also known as the designated record set. And lastly, it is important to highlight that psychotherapy notes have added protections under HIPAA, and they have the added protections under HIPAA if they are clearly designated in a separate tab within an electronic health record or for paper records are kept in a separate file. So these psychotherapy notes are defined as notes that document or analyze the contents of a therapy session and are separated from the rest of the record. The definition of psychotherapy notes specifically excludes patient information that is considered to be part of the medical record. For more information, please reference the Code of Federal Regulations 164.501. Solid documentation. So as we talk about documentation and making sure that we have a complete record in the event we need to defend in litigation or a regulatory complaint, or just in the event a patient does request their record, really, what elements should we be considering? Medical history. So it's important to have a complete medical history that's appropriate for the treatment purposes that you're seeing the patient. So again, when a patient starts care with you, make sure you have that past medical history that's appropriate. So again, the medical record tells a story from start to finish. What's their current mental status? Are there any current medications that the individual is on? Are you making med changes? Are there any side effects? No responsiveness or lack of responsiveness to treatment and any outcomes, follow-ups, or recommendations for changes. Are you ordering lab tests? If you are ordering lab tests, are you monitoring for the results and the outcome? Again, if there are results for lab tests, making sure that you are monitoring that those results are charted in the record and appropriate follow-up is communicated to the patient and documented in the record. Diagnosis and treatment. It goes without being said that obviously diagnosis and treatment is important for patient care as well as billing and justification for the care and treatment that you're providing. Informed consent and informed refusal. You know, again, patients have the right to refuse. They have the right to make those decisions through that informed process, whether it be they consent or they refuse. Document that. Suicidal or violent ideation. You know, this is a topic that has come to the forefront over the past several years. So it's recommended that the chart just not say no SIHI. Be thorough and descriptive in your documentation so that you're reflecting what is actually occurring with the patient. Be specific. Paint the picture so that an individual knows exactly what is going on with that patient if they are suicidal or if they're not expressing suicidal or homicidal ideation. Be clear in your documentation and use descriptive words. Document their adherence or non-adherence with treatment. You know, that documentation of non-adherence is critical in the event you do need to ultimately look to terminate or discharge. If you don't have documentation of that non-adherence, it's going to make it a lot harder of a picture and a story to tell that that patient had a pattern, had a history of non-compliance and this is why you're moving forward with termination. Any boundary issues. Is the patient not, you know, adhering to your office policies and procedures? Are they texting you outside of normal business hours for non-emergent issues? Are they continuously canceling appointments at the last minute asking for a reschedule? You know, are they, you know, maybe making inappropriate, you know, statements? Again, make sure that these types of situations are documented in the record. And then lastly, in the event you do need to discharge or terminate a patient, it's important for you to have the appropriate documentation of the thought process, the action, the discharge termination. Make sure that you're in compliance with your state, you know, regulations. A lot of times it's a 30-day notice through written notification, through certified mail. Also making sure if there's medications and prescription issues and appropriate referrals are documented. Always document objectively. Again, make sure you're telling that story. Remember that a patient has the right to review their record. And in psychiatry, a lot of times patients may not like how you're describing them or they might not like what you have to say about them. So again, be as objective as possible to avoid a patient alleging a complaint or being upset with what you've documented in the record. Use direct patient quotes. It's always a good idea when trying to describe a situation involving a patient that you use their direct words, patient states, patient reports, statements like this to ensure that you're appropriately depicting what exactly the patient has reported to you during the session. Avoid using personal opinions or comments regarding the patient. And then again, be descriptive. Describe the patient's behavior in detail. If the patient appears intoxicated, be descriptive. Patient has, you know, is, you know, appears is slurring their words, has a strong smell of alcohol. Don't make assumptions. Be descriptive. Is, you know, unable to pay attention or to keep their eyes, you know, open. Something that allows for the appropriate description and in detail as to exactly what the patient is presenting like. Again, without using judgment, documenting objectively. What are some considerations when you are still using handwritten records? While the majority of records have transitioned to electronic, there are some portions of the record that may still be in written format or some individuals may still be using a complete written record. So, it's important for you to use, you know, legible handwriting. You don't want someone to try to decipher what you're writing. It's important to also use black or blue ink. That is recognized as the professional ink to use, you know, and document timely. I can't stress the importance enough to make sure that that record is documented because the facts and our memories do fade over time. And so, if you're documenting, you know, during the session or even shortly thereafter the session, you know, it's going to reflect really the accurate depiction, you know, of the details of the session. Date and time and sign the note. Make sure your signature is legible with the appropriate credentials. Take credit for the work that is done. In the event you have an error, something that you wrote in the record that needs to be taken out, you would place a single line through that error and then initial it. You would also clearly know any addendums. If there was an addendum added several days later, weeks later, you would clearly know the reason for making that addendum. And again, dating it and initialing it with your credential. Make sure you're documenting formal consultations and also using standard abbreviations. Avoiding the use of non-standard abbreviations so that, again, someone who is not in your professional specialty isn't making an assumption of what you were trying to document in the record. Considerations with the electronic record. So, it's important to be mindful of, you know, copy and pasting functions. So, claims for which we see with electronic health records, most likely the contributing factors really have been, I say, human error as a result of the electronic function. So, copying and paste. If there's a drop-down menu that defaults to something, again, double-checking, triple-checking. Are you in the right patient record? Are you selecting the right drop-down? We're all working at a very fast pace, so make sure that you are revalidating the work you're doing before you're saving. Templates. Although templates, you know, they really can enhance documentation. They may result in inaccurate information, and they also may not be individualized to the patient's condition. And so, you might, you know, jeopardize really the story and patient factors by using a template in a situation. Templates shouldn't replace the narrative regarding the visit. So, a lot of times, the templates are in place so that you, you know, check appropriate boxes and you don't miss anything. So, lack of narrative often doesn't tell the full story, and it's necessary to tell the story so that you can really cover all aspects of the patient care and visit. So, email, texting, and electronic communication. If you have an electronic health record that has the ability to use a portal system where email and texting and any electronic documentation can be fed into the record, that is ideal. You know, however, keep in mind that you want to make sure you want to make sure that this communication does get scanned into the record as appropriate. Also, prescriptions. Some software programs have pre-program lists of prescription as a way to reduce, you know, time when entering prescription orders for dosing. So, this could easily result in an unintended medication error. So, again, be very cautious when using these types of systems. Don't get alarm or pop-up fatigue when it comes to allergies or other issues, warnings that may come up with the e-prescribing, you know, and make sure that you are revalidating any entries in the electronic record. So, how do we document special situations? We've talked about documentation. So, again, it's important to include all related conversations. So, telephone calls. When it comes to calls, it's important you're responding appropriately. You're documenting what the patient's saying using quotes. What was the reason for their call? You know, documenting your response. Was there any advice you provided? Did you advise the patient to go immediately to the emergency room or call 911, for example? You know, it's documentation is critical really to avoid, well, he said, she said in a conflict. You know, in the event of an adverse outcome or complaint, you want to make sure that it's clear that these types of messages were documented in the record. Consultation. Whether it's formal or just information, be sure you're documenting appropriately. Refusal for treatment. Again, as I mentioned previously, patients do have the right to refuse. They have the right, you know, to make their own decisions. Make sure that the patient's capacity is documented. If the patient has capacity to refuse treatment, make sure you're documenting that. So, as part of the informed refusal process, you as the provider need to explain the terms, the risks, and the benefits that the patient must face should they, for example, leave the hospital against medical advice, refuse many medication, refuse treatment, or any other intervention. So, again, we use the patient's words. Why are they refusing? Why are they refusing treatment? Why are they refusing medication or the referral? And document. Document that the patient is aware of the potential risks and that they still continue to refuse treatment. Patients' families may be very involved in care and participate. So, listen to the family and be opened to what they have to say. There could be additional information that could be critical to the patient care. For example, they might say that, you know, the patient's been depressed after, you know, having a breakup with a significant other. So, as we've increased the utilization of telehealth, our conversations and observations with the presence of family may be more prevalent. So, take advantage of what they can offer and then document, if appropriate. How do you document a threat or a complaint or litigation? So we're going to give a little caution here. Be objective when documenting any complaints. So, you know, if the patient is unhappy with the care and treatment, simply state patient is unhappy or expresses a concern. They're not happy with the medication that I've prescribed because it makes them feel drowsy. You know, explain to them, you know, explain what they're saying if they're complaining. If they're complaining regarding calling the board because they don't like how you've handled the situation. Well, you can certainly document that. But again, maintain your objectivity. And then, you know, patient states is very unhappy. They're angry, you know, about my, you know, on-call hours that I was not available. And they've advised me that they're going to be contacting the board of medicine. You could document that. Adverse outcomes, incidents, and incident reports. So again, most healthcare providers at all levels, including physicians, are responsible for completing incident reports. In the private practice, it might be, you know, up to you and your practice whether or not you're documenting this. But in most clinics, facilities, there is a incident or recurrence reporting procedure. So, it's important to utilize your reporting structure to document the incident and be objective and factual to really capture, you know, the essential details of the event. It's important not to blame yourself or others when completing any incident report, you know, but document the facts. Do not document in a medical record that an incident report was completed. You don't ever want to document that. You don't want to document in the record to say, refer to the incident report. It's important that this is kept separate because that incident report is typically used for internal purposes only and is not a part of the medical record. And so, again, you only want clinical information to be documented. So, if there was an adverse event or incident that occurred, let's say it was a medication event and it was the wrong dose of a medication, you can document that, the medication error in the record. But separately, you would document if your practice or facility, healthcare organization had you fill out an incident report, you would document accordingly on that incident report the greater details of the events that took place. So, how should we be documenting informed consent and refusal? Again, continue with the best practices. It's important to include. So, discussion of the risks of medication. So, is there any black box warnings? Are you using the medication for off-label use? And what about medication use in any children under 18? So, these are important things to be addressing and documenting. Are there any FDA advisories with these medications, especially with minors? Discussions of alternative treatment. So, if there is alternative treatment, what are the risks and benefits? And make sure you're documenting that. Documentation of the risks of not going forward with a treatment or in the event an individual is just outright refusing, you know, let's say, treatment or medication, you know, document the refusal and why. And then the risks of the patient foregoing the treatment. Should they refuse? It's important for you to document those conversations, and those conversations might also include discharge or termination in the event they continue to refuse and you don't feel that you are the appropriate provider. Have those conversations and you document so that the patient has a clear understanding of what to expect. Documentation and consenting for minors. So, before you treat minors, it's important you obtain the appropriate consent. It's also important to know your state-specific statutes for the age of consent for minors. There are some states that a minor can consent for mental health treatment as young as 12. So, be familiar with the age of consent in your state and also have that conversation with parents and the child when they come to you for treatment. In the event you are treating a patient of divorced or separated parents, the best practice and recommendation is always to obtain a copy of the custody agreement to verify who has the legal authority to consent for treatment to avoid any issues down the road. So, although that sometimes may, you know, cause a slight delay, ultimately it will save you in the long run so that you know that you are obtaining consent from the appropriate parent. Now, we're going to take a look at metadata and e-discovery and audit trails. So, with the transition to electronic records, it's so important for us to highlight the potential risks that we all face with using computers and all these electronic devices. So, electronic records go through a process known as e-discovery in litigation. And plaintiff attorneys have become very crafty and have requested the audit trail, also known as the metadata, which really happens behind the scenes when reviewing medical records. So, it's important for you to know that all the keystrokes that you make within an electronic record are recorded behind the scenes and can be accessed in the event there was ever a question on the credibility of the documentation in the electronic health record. So, the audit trail slash metadata in the technical terms is really a summary of all the log-on and log-off times. So, we all have passwords and log-on credentials. That audit trail within the computer system is going to show that. What was reviewed by whom and for how long? So, believe it or not, these electronic systems can show how long you were in the record. What did you look at? Did you stay on a screen? Did you surf to another one? Did you pay attention in a particular date range on a record? And then were any changes or additions, deletions made? And when were they made and by whom? So, again, as we talked about making changes and addending records and deleting things and not deleting things because we don't ever want you to do that, this is the reason why because that audit trail will show exactly what happened. And you don't want that to happen because, again, if there was ever a question, you want your e-discovery and your audit trail to really be seamless and have no issues in the event they do want to see that. So, what exactly does discovery of medical records look like in litigation? Well, in summary, a plaintiff attorney is going to request the medical records and they're going to review those medical records for any evidence of negligent care and any information that may impeach the credibility of the defendant in doubt. You know, the review of the documentation is going to allow the review of the documentation is going to allow the plaintiff's attorneys and their experts to assess the specific care provided and the timeliness. So, again, they're going to scrutinize that record from start to finish to look for any, you know, any kind of avenue to sneak in to alleged negligence. So, what exactly are they looking for? So, the specific areas that they're targeting when they're reviewing records, they're going to look for gaps in the story. So, essentially, is there something missing in the course of the treatment? So, they're going to look for the gaps and omissions. Plaintiff attorneys are going to search for any conflicting statements or contradictions in the record to question the care provided. Also, they're going to look at the admissions. So, looking at the start of care, so when that patient came to you, looking at the history, is there a complete history with the facts? Keep in mind, their job is to find gaps or omissions. So, they're going to thoroughly look at this chart from start to finish. So, believe it or not, there have been cases when a complaint has been filed or a lawsuit has been filed and alterations to the record have been made. So, I just talked about in the prior slides, metadata. This is where they can search for inconsistencies and use metadata to prove that edits were made. So, it's important to never alter records. So, you know, understanding that alteration, they will catch you by asking for that metadata. Legibility issues. So, for handwritten records, be sure to write legibly. You don't want a plaintiff attorney to guess what you're documenting. So, be clear and succinct in your documentation. So, late entries. So, late entries do happen from time to time. They should be the exception, not the rule. And so, if you do have to make corrections or addendum record, make sure that you're clear and justify the reason for the correction or addendum. Do not delete any entry. That should never happen. So, clearly amend and correct and state why you're amending the record. Make sure to sign and date the record accordingly. They may also be looking for unclear orders that may not have been followed up on. So, again, that attorney is looking to poke a hole in the care. So, it's important to have that documentation, which shows your follow through on all treatment. And then lastly, we've talked about consent. So, it's looking for your documentation that reflects that the proper person consented to treatment and that the record reflects their signature acknowledgement. So, again, attorneys are going to look for an incomplete documentation, which also may reflect an unsigned consent. So, sometimes we see records that have the consent in the chart. However, it's not been signed. So, how are they going to find out? As part of the litigation process, there's a process known as discovery. And through this phase, attorneys will investigate to build or defend their case. And so, they're going to compare medical records with the billing records. They're going to make sure that that medical record matches up with the billing that has been billed for the visit. They're going to compare different notes between providers, if multiple providers have seen the patient within the record. They're going to look at and compare the observations. Again, their job is to look for gaps or inconsistencies regarding documentation, observations. For handwritten records, they will specifically be looking at handwriting styles. You know, and while they can't request an audit trail, like they can in the electronic record, this is their way of auditing or reviewing a handwritten record by taking particular attention to the handwriting. They're also going to interview employees for verification of processes and procedures. Again, looking for any gaps or inconsistencies. So, the goal in all of these areas is going to be to reduce your risk for exposure by taking the steps that we've discussed throughout the presentation today. So, it's important to remember that someone else will read and need to understand what you have written in the medical record. So, ensure that it is clear and concise documentation. Ensure that it reflects decision making and interventions. Know that the record may be subpoenaed and subject to interpretation. Again, by being thorough in your documentation, that interpretation and subjectivity is going to be reduced because hopefully that you've painted a clear picture of the patient's status from start to finish. And that you may be called upon after a board complaint or in court to explain your documentation. And as I mentioned, it could be several years later that you have to look at this documentation and defend what exactly you wrote in that record. So, we've covered a lot of material today. However, if you keep these final thoughts at the forefront, you're well on your way to establishing a solid medical record. Know that your documentation is a reflection of the care that you provided to the patient and does reflect your professional credibility. Your documentation should always be succinct and tell the patient's story and describe the steps that you took as part of the treatment plan. It's important to remember your documentation will be reviewed at some point, whether it's by the patient, a regulator, or plaintiff or defense counsel. Keeping these final thoughts in mind will help you to mitigate these risks. So, the old rule, if it wasn't written, it wasn't done, that holds true, especially in healthcare and documentation. Always know that the patient has the right and will read their record under the right to access with HIPAA. And with the patient portal and ease of access to documentation, patients are often reading their records in real time. Accurate documentation really does depend on timely documentation. As I mentioned, our memories fade and details may fade. So, again, document contemporaneously so that you don't forget or omit any of these details. Your documentation does reflect your professional credibility. Your medical record documentation may be the one and only opportunity you have to tell your story and your documentation does need to be defensible. Lastly, documentation should never be altered. So, in summary, if you remember these two simple principles, that your patient's medical record should be an accurate representation of the care and treatment provided to your patient and their response to treatment, and that the medical record is a legal document, which may be used to defend you and the care you and your team provided to the patient, keep in mind how the record will be viewed in the court and by attorneys and jurors. By remembering these two principles, chart with the patient in mind, and secondly, chart with the jury in mind. You are well on your way to mitigating your risk with documentation. Thank you for your time today and listening to the presentation. If you have any questions about today's presentation or insurance needs, please contact the APA Endorsed Professional Liability Program, American Professional Agency, Inc., at 1-800-421-6694 or visit their site at psychiatry.apa.gov. At AmericanProfessional.com, www.americanprofessional.com. Thank you.

documentation

healthcare

risk management

claims

psychiatrists

informed consent

medical record

legibility

e-discovery