How Quality Documentation Can Reduce Harm and Support Care

July 8, 2021
Incorrect documentation causes harm

A radiation oncologist examined a 69-year-old woman for Stage l oral cancer on the right side of her tongue. The radiation oncologist documented a treatment plan for radiation therapy on the right lateral tongue and right upper neck. A medical record treatment volume note done by the radiation oncologist incorrectly indicated the left lateral tongue so the dosimetrist then created an entire treatment plan for the left side of the tongue. The physicist signed off on the radiation treatment plan as did the radiation oncologist. None of them recognized that the wrong side was documented.

Because the entire treatment course was delivered to the wrong side of the tongue, radiation to the right side of the tongue was prohibited. This necessitated invasive surgery – a modified radical neck dissection, partial tongue removal and left forearm free flap – along with chemotherapy. The pathology report following surgery revealed lymph node involvement and that the cancer had progressed from Stage I to Stage IV.

The patient filed a malpractice claim against the hospital that employed the radiation oncologist, the dosimetrist and the physicist alleging improper/wrong medical treatment. The claim was closed with a payment to the woman on behalf of the hospital.

The quality of documentation is a critical factor in reducing harm events and supporting your care in the event of a malpractice claim or lawsuit. In a malpractice claim, the documentation provides evidence of whether the standard of care was met and is a defense issue. However, insufficient or absent documentation can also cause harm events especially if deficient or incorrect documentation misleads subsequent treating clinicians as in this claim.

Malpractice claims with documentation deficiencies

An analysis of Constellation malpractice claims reveals that documentation deficiencies contribute to 15% of claims and accounts for 22% of costs.

The top allegations triggering claims with documentation deficiencies include:

  1. Surgical treatment: 26% claims; 20% costs
  2. Medical treatment: 23% claims; 11% costs
  3. Diagnosis-related: 18% claims; 19% costs
Constellation Allegations with Document Deficiencies

The top responsible clinicians and teams involved in these claims are:

  1. Nursing: 16% claims; 9% costs
  2. Family medicine: 11% claims; 21% costs
  3. Obstetrics: 8% claims; 4% costs
  4. Emergency medicine: 7% claims; 20% of costs

Of note, family physicians and emergency medicine specialties combined for a total of 41% of costs when documentation deficiencies were a contributing factor.

Quality documentation can reduce harm and support care

Improving the quality of documentation can improve communication among the care team, reduce the risk of harm events and support your care in the event of a malpractice claim.

“Organizations should establish written policies and guidelines outlining medical record documentation standards. All clinicians and team members should be completely familiar with the organization’s documentation requirements and expectations.”

Betty VanWoert, Senior Risk Consultant at Constellation

Written policies also provide the basis for training to ensure quality documentation. Assessment of current documentation practices will identify problem areas that require attention. Regular, systematic medical record review will help monitor if documentation standards are being followed. The information obtained from medical record reviews will identify where deficiencies exist, where current policies are not being followed and where training or retraining needs to occur.

The HEAL Prepare Toolkit

Our HEAL Prepare Toolkit helps your organization prepare and respond to harm events. Unit 2, Event Response, can help you understand how contributing factors, like documentation deficiencies, can disrupt communication among the team, affect clinician decision-making leading to harm and cause difficulties in defending allegations of malpractice.

Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) patient communication, and (4) moving forward. Sign in to to access the HEAL Prepare Toolkit found in Risk Resources.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.

Constellation and HEAL are trademarks of Constellation, Inc.


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