{"id":14778,"date":"2021-12-27T15:13:00","date_gmt":"2021-12-27T15:13:00","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14778"},"modified":"2025-08-27T09:23:24","modified_gmt":"2025-08-27T09:23:24","slug":"avoid-malpractice-risk-by-correct-documentation","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/avoid-malpractice-risk-by-correct-documentation\/","title":{"rendered":"Avoid Malpractice Risk by Correct Documentation"},"content":{"rendered":"

According to the recent research report, approximately 5 percent of family physicians and 7 percent of all physicians are sued for malpractice in the United States each year. The incidence of lawsuits is much greater in some surgical subspecialties, with annual rates approaching 20 percent among neurosurgeons and cardiothoracic surgeons. <\/span><\/p>\n

For low-risk specialties including family medicine, the annual incidence of claims resulting in compensation to patients or their families is only about 1 percent. Still, an estimated 75 percent of physicians in lower-risk specialties will face a malpractice claim by age 65. Some claimants may not be able to find a lawyer with the resources to accept the case on contingency. <\/span><\/p>\n

As a result, more complaints are being processed by medical boards, which may result in no action, a letter of reprimand, probation, or in rare cases, revocation of the physician\u2019s license to practice. Correct and complete documentation is a strong source that could help you in case of such malpractice claims lawsuits.<\/span><\/p>\n

In this article, we shared basic documentation guidelines which will help you to avoid malpractice claims lawsuit risks.\u00a0\u00a0<\/span><\/p>\n

Basic Documentation Guidelines to Avoid Malpractice Claims Lawsuit Risks.\u00a0\u00a0<\/span><\/h2>\n

Excellence in medical documentation reflects and creates excellence in medical care. At its best, the medical record forms a clear and complete plan that legibly communicates pertinent information, credits competent care, and forms a tight defense against allegations of malpractice by aligning patient and provider expectations. <\/span><\/p>\n

When physicians are viewed as dispensers of advice and patients as followers of that advice, the credit or burden for clinical outcomes goes to the physician. Careful documentation can mean the difference between a guilty verdict and a case being thrown out. It\u2019s worth the trouble to make sure you do it right.<\/span><\/p>\n

1. Document Your Diagnosis in Detail<\/span><\/h3>\n

If your note doesn\u2019t indicate how you arrived at a differential diagnosis, you\u2019re asking for trouble. In the absence of contrary evidence, juries will assume the worst. For instance, if your patient has chest pain, do more than simply list GERD as your diagnosis. Instead, you might write, \u2018Likely GERD; with this atypical history, less likely to be an acute coronary syndrome or musculoskeletal chest pain, etc.\u2019 Then go down the list and document that you talked about it with the patient. <\/span><\/p>\n

Also, avoid false certainties. A good example is a patient who turns out to have appendicitis when the doctor has documented simply \u2018gastroenteritis.\u2019 A more complete documentation of the doctor\u2019s thought process would probably be something like this: \u2018Abdominal pain, unclear etiology. <\/span><\/p>\n

The risk of appendicitis is low, and given that a CT scan would expose this young person to a lot of radiation, I think the risks of doing the CT scan outweigh the benefits. Therefore, we\u2019re going to monitor for improvement and then proceed with if necessary.\u2019<\/span><\/p>\n

2. Shared Decision Making with Patients\u00a0<\/span><\/h3>\n

If you practice shared decision-making with your patients, be sure your notes reflect it. If your notes convey physician-centered decision-making, they may offer less protection in a lawsuit. The benefits of shared decision-making go well beyond avoid malpractice risk.<\/span><\/p>\n

Shared decision-making involves explaining the alternatives open to the patient, along with their risks and benefits, and agreeing on a plan. The discussion and agreed plan should be documented. Specificity is important; a boilerplate note such as \u2018risk-benefit assessment discussed\u2019 is no longer adequate protection in a malpractice case.<\/span><\/p>\n

3. Define Goals<\/span><\/h3>\n

A study of primary care physicians<\/a> in Colorado and Oregon noted that physicians who use more orienting statements, such as explaining what will likely happen next, are less likely to be sued. Document any warnings given or risks discussed. A useful phrase in communication and documentation is \u2018recheck if not better.\u2019 <\/span><\/p>\n

Asking for the patient\u2019s opinion and checking his or her understanding during the visit also reduces liability. End with a concise phrase such as \u2018patient understands and agrees.\u2019 At our clinic, we give patients an \u2018after visit summary\u2019 that includes the diagnosis made, orders given including phone numbers for consultations and testing, and patient instructions. If you give the patient an after-visit summary or any other information to take home, be sure to document it.<\/span><\/p>\n

Above mentioned documentation guidelines will surely help you in reducing malpractice claims risk. But still, if you need any assistance in billing, coding, and medical documentation, <\/span>MedicalBillersandCoders (MBC)<\/b> can help. We provide complete revenue cycle management services, that include charge entry, payment posting, denial management, revenue cycle reports, account receivable management, provider credentialing, enrollment, and many other services. <\/span><\/p>\n

We have an expert billing team that provides customized billing solutions as per your practice requirements. To know more about our revenue cycle billing services<\/a>, contact us at info@medicalbillersandcoders.com<\/a>\/ 888-357-3226.<\/a><\/span><\/p>\n

FAQs<\/h2>\n\n\n
1. How can detailed documentation help in defending against malpractice claims?<\/strong><\/strong>

Thorough documentation, including a clear explanation of your diagnosis, differential diagnosis, and decision-making process, provides a strong defense in the event of a malpractice lawsuit. It shows the rationale behind your medical decisions and can prevent misinterpretation by juries.<\/p> <\/div>

2. Why is shared decision-making important in medical documentation?<\/strong><\/strong>

Shared decision-making ensures that patients are fully informed about the risks and benefits of their treatment options. Documenting these discussions and the agreed-upon plan can protect you in malpractice cases by demonstrating patient involvement in their care decisions.<\/p> <\/div>

3. How can defining goals and setting expectations reduce malpractice risks?<\/strong><\/strong>

Defining goals during patient visits, such as explaining next steps or recheck instructions, helps ensure that both you and the patient are aligned. Documenting these goals, along with patient understanding and agreement, can reduce liability by showing clear communication and patient consent.<\/p> <\/div>

4. What are the best practices for documenting shared decision-making?<\/strong><\/strong>

When practicing shared decision-making, it\u2019s crucial to document the alternatives discussed, along with their risks and benefits. Avoid generic phrases like \u2018risk-benefit assessment discussed.\u2019 Instead, be specific and include the patient\u2019s preferences and the agreed-upon plan.<\/p> <\/div>

5. How can MedicalBillersandCoders (MBC) assist with billing, coding, and documentation?<\/strong><\/strong>

MBC provides complete revenue cycle management services<\/a>, including billing, coding, and documentation assistance. Their expert team offers customized solutions tailored to your practice\u2019s needs, helping you streamline processes and ensure compliance while reducing malpractice risks.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"

According to the recent research report, approximately 5 percent of family physicians and 7 percent of all physicians are sued for malpractice in the United States each year. The incidence of lawsuits is much greater in some surgical subspecialties, with annual rates approaching 20 percent among neurosurgeons and cardiothoracic surgeons. For low-risk specialties including family […]<\/p>\n","protected":false},"author":2,"featured_media":14782,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[3050,3051,3052,603,18,3053,3054,3055,604,70,2467,3056,611,3057],"class_list":["post-14778","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-account-receivable-management","tag-avoid-malpractice-claims-lawsuit-risks","tag-basic-documentation-guidelines","tag-charge-entry","tag-denial-management-2","tag-enrollment","tag-family-physicians","tag-malpractice-claims-lawsuits","tag-payment-posting","tag-primary-care-physicians","tag-provider-credentialing","tag-reducing-malpractice-claims-risk","tag-revenue-cycle-management-services","tag-revenue-cycle-reports"],"yoast_head":"\nAvoid Malpractice Risk by Correct Documentation<\/title>\n<meta name=\"description\" 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