business of Medicine


Onboarding Advanced Practice Clinicians

August 1, 2019

Medical records and documentation

Timely dictation, review, and filing of reports

To facilitate continuity of patient care and ensure corporate compliance, it is recommended that medical practices establish an organization-wide policy to track and address medical record delinquencies, and ensure that dictation, transcription, and the filing of medical records are completed accurately and in a timely manner. Medical record statutes, regulations, and accreditation standards all require healthcare providers to maintain complete records. The medical record serves as the main communication tool between all members of the healthcare team. The medical record should support and help coordinate the medical care of a patient.

Timely dictation, review, and reconciliation are important in facilitating the flow of information among the providers involved in the patient’s care. In today’s complex healthcare delivery environment, requiring an exceptional amount of coordination among the various providers involved in the care of a patient, it’s easy to see why communication errors are frequently cited as one of the leading causes of medical errors.

Obtaining and analyzing medical records is a critical component when reconstructing the medical treatment of a patient. Approximately 35-40% of all medical malpractice suits are rendered indefensible because of problems with documentation in the medical record and/or the management of the medical record in general. A complete record, with factual, objective documentation of the care rendered, is the provider’s most effective defense in the event that the provider is sued for medical malpractice.

As part of the discovery process, lawyers may request not only printed copies of the electronic health record (EHR), but also the audit trail for metadata analysis. This includes logon and logoff times, what was reviewed, and for how long, what changes or additions were made, and when those changes were made. A record entry completed long after a patient encounter, or at the time an attorney is requesting the medical record, is likely to hurt that provider’s defense.

It is clear that inadequate, incomplete, or untimely completion of medical records expose the physician and the hospital to risk. Hospital rules and regulations and medical office policies and procedures should be strictly enforced to enhance patient care and to avoid potential legal exposure.

Documentation of patient encounters

The documentation of each patient encounter should include at least the components discussed in this Advisory.

The Chief Complaint

Include a statement as to why the patient came to the office or document a chief complaint. Failure to diagnose and delays in diagnosis are common allegations in medical liability claims. Document the patient’s complains in quotes, when applicable. Include pertinent information such as the onset and duration of the complaint.1

History of Present Illness

Document the description of the patient’s present illness from the first sign or symptom or from the previous encounter. If you ask the patient to complete a questionnaire, acknowledge the document as evidence of your review. Pertinent Findings and Observations of the Physical Examination.

Documentation of the physical examination should include:

  • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s). A notation of “abnormal without elaboration is insufficient.”
  • Abnormal or unexpected findings of the examination of any unaffected or asymptomatic body are(s) or organ system(s)
  • A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ systems.2 Please note that both positive and negative findings should be documented as appropriate. For example: A patient presents with chest pain; positive findings are pain on inspiration, cough, sputum production; pertinent negative findings are no family history of heart disease, normal cholesterol profile...etc.
  • Document vital signs for patients presenting with an acute illness, and before and after an invasive procedure.

The problem list in the medical record

The problem-oriented medical record1 was proposed as a way to help physicians track patient’s problems. While rarely implemented in full, many believe aspects of the problem-oriented medical record could assist quality and error reduction efforts in medicine.2 The practice of maintaining a problem list within the traditional medical record has established itself as a compromise for achieving many of the benefits of the problem-oriented medical record without losing key advantages of the traditional chronological medical record. The patient problem list is traditionally a simple list of a patient’s medical and social problems that “encourages doctors to think holistically about their patients and means that minor problems are less likely to be forgotten”.3

As a result, the Institute of Medicine (IOM) recommends use of a problem list and The Joint Commission (TJC) requires one as an element of a complete medical record.4

Maintaining an up-to-date problem list of current and active diagnoses is also one of the core measures in the Medicare & Medicaid EHR Incentive Program, Meaningful Use Requirement, incorporated into Stage 2.5

Accurate, active problem lists have been a mainstay of efficient and effective primary care for years, providing a fast overview of a patient’s history. A patient problem list is subject to change during each appointment, whether it is by adding new information or removing outdated information. Providers utilize their nursing staff by having them review the problem lists when preparing the patient’s chart. Any notes regarding rehabilitation or specialty care trigger an in-depth review to ensure the patient problem list is all inclusive. Providers also utilize clinical summaries as a mechanism for review and correction of problem lists, encouraging their patients to be active in their care and identify when there might be outdated information such a obesity or smoking status.

Prior to using EHR’s providers depended on paper charts and faxes to be certain their patients had accurate problem lists. Now, not only is problem list maintenance easier, but an EHR provides this information to all clinical staff, making their time with the patient much more efficient. Finally having quick and easy access to a current problem list improves the efficiency and effectiveness of your practice’s on-call team during evening/weekend coverage.

Providers are encouraged to standardize their problem lists in the EHR and to take further steps to:

  • Learn how the problem list can be leveraged to achieve better individual patient care and population management
  • Understand the opportunities and barriers for a standardized problem list in the EHR and
  • Learn how to develop processes to standardize problem list maintenance.

Vital signs: vitally important

Errors in diagnosis, failure to supervise or monitor case, and failure to recognize a complication of a treatment are among the top five most prevalent medical factors associated with medical liability claims.1 Further, for those cases in which an associated medico legal issue was included in the allegation against the practitioner, problems with a patient’s history, exam or work-up was most prevalent.2

Below are some of the more common factors leading to diagnostic errors:

  • Inadequate patient-provider communication
  • Incomplete medical history documentation
  • Failure to examine the patient
  • Failure to order diagnostic tests
  • Follow-up and tracking diagnostic information
  • Interpretation of tests
  • Patients not referred to a specialist

Accurate, documented vital signs are an important component of patient care. They provide essential, baseline data for treatment decisions and historical trends. This historical information allows for recognition of acute or chronic changes that may prove significant.3 Ignoring basic findings, such as vital signs, is a common factor that leads to diagnostic error. These lapses interfere with appropriate and timely interventions for deteriorating patients. All too often physiologic abnormalities that develop up to 24 hours prior to death are either undocumented or unrecognized.

In the medical office setting, at minimum, vital signs should be taken and recorded for patients presenting with an acute illness, procedures, and high-risk treatments.

MagMutual offers two online CME presentations that address issues related to diagnostic errors. These following educational activities can be found on the MagMutual website at

  • Misdiagnosis: Time is of the Essence
  • Missed or Delayed Diagnosis: Lessons from Lawsuits

Documentation of body mass index (BMI) and follow-up plan

Obesity is associated with such health problems as an increased risk for coronary artery disease; type 2 diabetes; various types of cancer; gallstones and disability.1 These comorbid medical conditions are associated with higher use of health care services and costs among obese patients.2 Obesity is also associated with an increased risk of death, particularly in adults younger than age 65, and has been shown to reduce life expectancy by 6 to 20 years depending on age and race.3

In 2012, the U.S. Preventative Services Task Force (USPSTF) updated its recommendations regarding screening for obesity and overweight in adults. The USPSTF recommends screening all adults for obesity and referring patients with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.4

Underscoring the significance of obesity, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.

The measure pertaining to obesity is Measure #128.; the percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months and when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter.5

As cited in Wilkinson et al. (2012), Institute for Clinical Systems Improvement (ICSI) Preventive Services for Adults, Obesity Screening(Level II) Recommendation provides the following guidance:

  • Record height, weight and calculate body mass index at least annually
  • A BMI greater or equal to 30 is defined as obese
  • A BMI of 25-29 is defined as overweight
  • Intensive intervention for obese individuals, based on BMI, is recommended by the U.S. Preventive Services to help control weight.6

A treatment plan should be tailored to meet individual needs of the patient. When developing a plan, healthcare providers consider many factors, including the patient's overall health and his or her personal preferences.

A combination of the following therapies may be considered to develop an effective treatment plan:

  • Low calorie diets
  • Very low calorie diets
  • Behavior modification
  • Exercise
  • Medications
  • Surgery

Refer to Institute for Clinical Systems Improvement (ICSI) Preventive Services for Adults, Obesity Screening, (2012) for implementation recommendations and resources.

Preventative care and screening for hypertension

Hypertension is the most common reason for adult office visits other than pregnancy.1 According to Garrison (2013), in 2007, approximately 42 million ambulatory visits were attributed to hypertension.2 Hypertension leads to myocardial infarction, stroke, renal failure and death if not detected early and treated appropriately. The condition affects approximately 66.9 million people in the United States. It is estimated that about 20-40% of the adult population has hypertension; the majority of people over age 65 have a hypertension diagnosis.3

Underscoring the significance of hypertension, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data quality measures for covered professional services.

The measure pertaining to screening for hypertension is Measure #317; the percentage of patients aged 18 years and older who were screened for high blood pressure and who were given a recommended follow-up plan is documented based on the current blood pressure reading as indicated.4 The United States Preventative Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 years and older. This is a grade “A” recommendation, which means that there is a high certainty that the net benefit is substantial.5

In 2014, the panel members appointed to the Eighth Joint National Committee (JNC8) issued nine (9) evidenced-based guidelines for the management of high blood pressure in adults.6 The recommendations are as follows:

Recommendation 1 In the general population aged 60 years and older, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP

Corollary Recommendation In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg,

Recommendation 2 In the general population

Recommendation 3 In the general population

Recommendation 4 In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP

Recommendation 5 In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP

Recommendation 6 In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B)

Recommendation 7 In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

Recommendation 8 In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)

Recommendation 9 The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes may be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E)7

To review the entire report, refer to the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)." Journal of the American Medical Association, February 5, 2014: 507-520, DOI

Documenting an assessment/working diagnosis

Providers should document an assessment, clinical impression or a diagnosis at each patient encounter. This establishes the medical decision making process and establishes your general observations or opinion of the patient’s condition.1

Providers often use a “working diagnosis” to establish a direction for further evaluation or treatment. The working diagnosis may not be given a name but may be documented as a care plan, group of possibilities (differential diagnosis) or concern. The evaluation of patient complaints, management of chronic illness, and provision of preventive health services may defy definitive diagnosis. The working diagnosis offers a plausible destination on the patient care path in an outcome-oriented system.

Unless the provider is certain of the condition present, further medical tests, such as medical imaging, are performed or scheduled in part to confirm or disprove the diagnosis but also to document the patient's status and keep the patient's medical history up to date. During the physical examination, both positive and negative findings should be documented as appropriate. For example, a patient presents with chest pain; positive findings are pain on inspiration, cough, sputum production; pertinent negative findings are no family history of heart disease, normal cholesterol profile...etc. Findings that are unexpected may direct another plan of action; patient refusals, decisions to avoid a workup, or other reasons that alter care plans should be documented.

The provider should educate the patient about the etiology, progression, prognosis, other outcomes, and possible/proposed treatments of her or his ailments, as well as provide advice for maintaining health. These discussions should be documented. The provider should also document the patient’s understanding and acceptance of the treatment plan, as well.

If the patient fails to respond to treatments that would normally work for a specific diagnosis, it may be time to revisit your rationale for making that diagnosis, and begin pursuit of another cause. Your rationale for ordering tests, and diagnostic procedures, change in diagnostic pursuit should all be fully explained in the medical record.

Documenting an action plan in the medical record

An action plan includes the nature of each patient encounter, the recommended timeframes for treatment, and the provider’s treatment rationale. At each patient visit, the medical record should clearly show the provider’s present and future plan for treatment, including his/her rationale for conducting diagnostic tests and making referrals to specialists.

The action plan should be a collaborative and individualized agreement between the patient and the provider concerning planned tests, treatments and follow-up care. It is important that the patient agree to and understand the plan of care. Studies in ambulatory settings show that these type agreements between patients and physicians are associated with improved medication adherence and better patient outcomes.

The patient’s failure to keep an appointment does not relieve the physician of his/her obligation to notify the patient of abnormal findings or the consequences of failing to obtain follow-up care. Physicians should make a reasonable effort to contact the patient who missed a scheduled appointment or test. If the patient cancels the appointment, every effort should be made to reschedule the appointment as soon as possible. All follow-up attempts, usually three, to contact the patient and the patient’s stated reasons for missing appointments should be carefully documented in the medical record. We advise the last attempt be in writing, clearly explaining why the follow-up is necessary, and the potential consequences of failure to do so. Mail the letter certified and/or return receipt requested.

Although it is reasonable for providers to expect a patient to share in the responsibility for their own care, juries nationwide have placed a significant amount of responsibility for follow up and carrying out of the designated action plan, on the provider. When patients fail to follow treatment advice, or keep appointments, it is prudent to document this in the medical record. If the patient’s failure to follow the mutually agreed upon treatment plan contributes to an injury resulting in a malpractice suit, this fact can often be introduced as evidence in the doctor's defense. Documentation of patient failed appointments can provide a powerful defense to any lawsuit.

In carrying out the action plan, a reliable clinical tracking system is important in identifying patients who fail to keep scheduled appointments for tests and consultations with specialists. Whenever possible, schedule referrals and follow-up appointments before the patients leave the office. Failure to maintain a reliable clinical tracking system is one of the most frequently cited problems in medical malpractice cases where there is an allegation of delay in diagnosis and/or failure to supervise care.

Tips for providing & documenting effective patient education

Since 1993, The Joint Commission has extended the responsibility for patient education to all healthcare providers. The educated patient is typically better able to co-operate with her healthcare providers and participate in her treatment plan. The American Medical Association suggests providers document in the medical record when written education materials are provided to the patient and/or others involved in the patient's care/education.1

Education provided must be documented in the Medical Record. Documentation of patient education is part of the final step in the patient education process. As the old saying goes, if it isn’t documented, it wasn’t done. Remember, too, that attorneys who might represent you can draw only from the documentation you have provided.

Here are some tips for providing and documenting effective patient education:

  1. Provide the patient with instructions and materials that are appropriate for the patient's age, cultural beliefs, experience, understanding and readiness. For example, when working with a low-literacy patient, consider using visual aids or hands-on activities instead of wordy pamphlets or brochures.
  2. Consider potential barriers to the patient's learning and devise a plan that helps the patient overcome them. A few examples of such barriers (among others) might be: financial limitations, lack of motivation, low literacy and comprehension skills, language barriers, negative past experiences, or misconceptions about disease and treatment.
  3. Provide counseling and educational materials on a variety of topics that are relevant to your patients' needs and concerns. Some examples of these topics might be: immunizations, nutrition, smoking cessation, substance abuse, family planning, breast self-examination, stress management.
  4. Provide education and counseling about chronic disease management. Educating patients about topics like asthma, arthritis, obesity, depression and anxiety, and other chronic conditions can lead to improved health outcomes and reduced overall healthcare costs.
  5. Encourage the patient to ask questions and provide appropriate answers.
  6. When dealing with a patient's acute illness, prepare the patient for the symptoms and effects of the condition, examination and treatment. Identify potential barriers to the treatment plan and address them accordingly.
  7. When devising long-term strategies for chronic disease, provide the patient with manageable information over time. Involve the patient in setting manageable goals, and provide the patient with feedback on his or her progress. For example, help an obese patient set manageable weight loss goals, and provide positive feedback as the patient works toward reaching those goals.
  8. Determine the patient's at-risk behaviors through interviews and health appraisals, and address any potential risk factors. Also introduce health promotion topics during "teachable moments." For example, if a patient comes in to be tested for sexually transmitted infections (STI), provide the patient with education on sexual health and contraception.
  9. Develop systems to facilitate the use of patient education materials in the office practice, and develop systems to involve office staff with assisting with patient education.
  10. Be aware of emerging technologies and consider how they might be used to provide patient education and counseling.
  11. Ensure that your verbal discussions and written materials are appropriate for the patient's age, cultural beliefs, experience, understanding and readiness. Typically, these materials are prepared at the 6-8 grade levels. For example, when working with a low-literacy patient, consider using visual aids or hands-on activities instead of wordy pamphlets or brochures.2

Documenting patient non-compliance: a powerful defense

Non-compliance in (healthcare) is a coined term used to classify patients who fail, for one reason or another, to follow health care direction given by a professional. Among the more common problem areas are:

  • Repeated failure to keep appointments
  • Failure to have diagnostic testing or consultation as recommended
  • Failure to comply with medication therapy
  • Failure to follow medication monitoring recommendations (for example, warfarin monitoring)

In this article we discuss the prevalence of “noncompliance”, “non-compliance v patients’ right to make healthcare decisions, tempering the use of the term so as not to inaccurately label patients, assisting patients in following healthcare advice or coming up with options, and what to do when your patient refuses to sign an informed consent form.


The problem of patient non-compliance is well-documented. According to a study published by the Food and Drug Administration (FDA) and the National Council on Patient Information:1

  • 14-21 percent of patients never fill their original prescription
  • 60 percent cannot name all the medications they are taking
  • 30-50 percent fail to follow the instructions for taking a medication

In another comprehensive compilation of research on the prevalence and incidence of patient noncompliance, Dr. Sallan Showalter summarized his findings in what he called “The No-Nonsense Summary, Incidence and Prevalence of Patient Noncompliance":2

  • Patient noncompliance is pervasive
  • Any patient in any practice is at high risk for noncompliance
  • Clinical instinct cannot detect noncompliance
  • No methodology accurately predicts which patients will and will not adhere to a treatment plan

Non-Compliance versus Patient’s Right to Make Decision Regarding Medical Treatments

It is important to recognize the difference between non-compliance and the patient’s right to refuse care. Patients have the right to make informed decisions regarding their care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. The failure to follow treatment advice may be the result of an educated, rational and reasonable decision on the patient’s part to exercise control over their healthcare. The medical record should include documentation that the diagnosis and proposed procedure/treatments were explained to the patient and that the explanation included the patient’s prognosis without the procedure, the risks and benefits, and alternative therapies. In the absence of this documentation, it may be alleged that the patient would have elected to follow the recommended advice had they understood its importance.

What should be done if a patient refuses to sign an Informed Consent form?

The patient’s refusal to sign an informed consent form poses risk management concerns. Investigation into the reasons for the refusal should be fully explored with the patient and documented in the medical record. It is advisable to have a third party, such as the office nurse or other office professional, witness this discussion. The name of the witness and/or signature should be included in the medical record notation.

If the rationale for the refusal is due to an unwillingness to undergo the procedure or treatment plan, then the procedure or treatment should not proceed, and attempts at obtaining a refusal of treatment form should be pursued with the patient. In this instance, it is imperative that a specific notation of the discussion with patient be expressly documented in the medical record. If the reason not to sign the informed consent form is for other reasons, it is suggested that a notation indicating the patient’s reasoning be made in the medical record.

Reasonable doubt regarding the patient’s intent for refusing to sign an informed consent form may be grounds to temporarily suspend the procedure or treatment protocol.

The patient has the right to refuse care and treatment. When the patient has had the risks and benefits of the proposed treatment options explained, and his/her questions answered and then refuses to go forward with the proposed treatment plan, the conversation should be documented as an informed refusal discussion. Good documentation principles suggest the medical record reflect the need for the proposed procedure, the risks, benefits, and alternatives, the consequences of refusal that were discussed, and the reason the patient stated for the refusal.iii

The physician may ask the patient to sign an “Informed Refusal” form. In these situations, while patients generally cannot “sign away” their legal rights, their signatures on such documents may constitute valuable evidence that these discussions did in fact occur.

Strategies to Enhance Compliance

It is important to consider the reasons that patients fail to follow treatment plans and make reasonable attempts to facilitate compliance. Prevention remains the best risk management strategy.

Consider the following suggestions to enhance patient compliance:

  • Explain the rationale for the treatment advice
  • Allow the patient to voice any concerns they have about recommended treatments
  • Suggest treatments that are reasonable, taking into account the patient’s lifestyle, finances and ability to comply
  • Whenever possible, give patients the opportunity to think about proposed treatments prior to making a final decision
  • Provide simple written information to patients and others who are involved in their care
  • Attempt to gain agreement on the treatment plan

Additional Strategies

Document Non-Compliance/Informed Refusal Carefully notate episodes of the patient’s failure to follow the healthcare plan, avoiding any documentation that may look judgmental. An example of an adequately documented informed refusal discussion is as follows:

“A breast ultrasound has been recommended to evaluate the palpable lesion on the right breast. The patient states that her insurance “will not be effective for ninety days” and elects not to have the test done pending coverage by insurance plan. The risk of delay was discussed with the patient to include the possibility of a malignancy, and the risks of a potentially life threatening delay in diagnosis and treatment. The patient verbalizes understanding of the information provided. I have asked my staff to investigate and advise her of any financial assistance that may be available. She was advised to contact me as soon as possible if she reconsiders this decision or as soon as insurance coverage is effective.”

A sample informed refusal form can be found on the MagMutual website at or call 1-800-282-4882 and ask for Risk Management.

Educate Patients Educate patients regarding recommended treatments. Emphasize the seriousness and urgency of any recommended tests. Be cautious with reassurance as the patient may interpret this to mean that the test is not important.

Document Screening Recommendations Advise patients of preventative health screenings and document these discussions. Failure to do so could result in an allegation of a delay in diagnosis if a metastatic or potentially life-threatening condition is not detected in a timely manner.

Maintain a Reliable Clinical Tracking System Without a reliable clinical tracking system, it may be difficult to identify patients who fail to keep scheduled appointments for tests and consultations with specialists. Whenever possible, schedule referrals and follow-up appointments before the patient leave the office. If the patient refuses the test, due to financial or other reasons, this should be well documented. The patient will remain active in the tracking system until one of three potential outcomes occurs: (1) follow-up is complete; (2) informed refusal is documented, or (3) there have been reasonable attempts (usually three) to encourage patient compliance. Document all attempts to contact the patient. We advise the last attempt be in writing, clearly explaining why the follow-up is necessary, and the potential consequences of failure to do so. Mail the letter certified and/or return receipt requested.

Coordinate Treatment Plans with Other Providers Involved in the Patient’s Care Maintain good communication with others involved in the patient’s care and maintain a clear understanding of the expectations and role in the patient’s plan of care. Consultant should notify you if the patient fails to keep an appointment and should also provide periodic updates on the care and treatment plan or a summary at the conclusion of care, whichever is appropriate.

When all else fails…Terminate the Patient Physician Relationship If the physician feels that the patient’s non-compliance is putting them at risk, they may decide that it is best to end the relationship with a patient. Prior to making this decision, it is prudent to step back and evaluate whether they have done everything within reason to preserve the relationship. If the decision is made to terminate the relationship, the provider should send a withdrawal letter by certified mail, return receipt requested.


Given the extensive research on patient non-compliance, it is reasonable to maintain a high index of suspicion for non-compliance on all patients. The best approach is to maintain effective communications with patients and take proactive measures to enhance treatment goals. However, when patients fail to follow recommended advice and a poor outcome results in a medical malpractice claim, objective documentation of non-compliance can be a powerful defense.

Authenticate medical record entries

Authentication is an attestation that something, such as a medical record, is genuine. The purpose of authentication is to show authorship and assign responsibility for an act, event, condition, opinion, or diagnosis.1 Every entry in the health record should be authenticated and traceable to the author of the entry. The Rules of Evidence indicate that the author of the entry is the only one who has knowledge of the entry. The Federal Regulations/Interpretive Guidelines for Hospitals 482.24(c) (1) (i) require that there be a method for determining that the author did, in fact, authenticate the entry.2 Facilities should have an effective system of author identification for medical records to ensure the integrity of the authentication.

The system should identify practitioners and personnel who are authorized to utilize the electronic medical record and other patient care systems. This includes verification of the author of faxed orders/entries or computer entries. This process should be defined in the practice’s written policies and procedures and substantiates the authentication of an entry in a legal process. The practice should require that each author takes a specification to verify that the entry being authenticated is his/her entry or that he/she is responsible for the entry, and that the entry is accurate. It is important that policies and procedures are in place to address misuse of a user’s unique identifier.

If allowed by state, federal, and reimbursement regulations, electronic signatures are acceptable as authentication. Electronic signature technology should provide verification of the identity of the author.3

According to the Federal Regulations Interpretive Guidelines §482.24(c) (1)4:

  • All entries in the medical record must be legible. Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.
  • All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard.
  • All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.

The time and date of each entry (orders, reports, notes, etc.) must be accurately documented. Timing establishes when an order was given, when an activity happened or when an activity is to take place. Timing and dating entries is necessary for patient safety and quality of care. Timing and dating of entries establishes a baseline for future actions or assessments and establishes a timeline of events. Many patient interventions or assessments are based on time intervals or timelines of various signs, symptoms, or events. (71 FR 68687)


It is important to remind medical record authors and others that in an electronic record, the metadata is the data about data. It reveals when files were created, modified, and accessed. This includes time and date stamps and far exceeds what was discoverable in a paper record. With advances in forensics, examiners can even see how long you view a particular screen.

In Summary

All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided.5

Making corrections to the medical record

Every practice should establish a policy and procedure for correcting medical records, whether paper or electronic (EHR). A correction is a change in the information meant to clarify inaccuracies after the original document has been signed or completed. It is acceptable to make an addendum to a medical record. It should be made after the last entry noting the current date and time, and both entries should be cross-referenced. A record that appears to have been altered implies that a cover-up has occurred. Never improperly or unlawfully alter a medical record.

If an error has been made in a paper record, draw a single line through the inaccurate entry and enter the necessary correction. Enter the date and time and initial the correction in the margin. Questionable medical record corrections or additions, e.g. notes in the margin, writing between the lines, erasures, etc. should be avoided.

Correcting errors in the electronic record should follow the same basic principles as correcting errors in paper copies. The following specific considerations apply to the EHR.

  • Work with your vendor to confirm that your EHR system allows error correction, and whether or not the vendor has established a process.
  • The system should have the ability to track corrections or changes once the original entry has been entered or authenticated.
  • When correcting or making a change to an entry, the original entry should be viewable, the current date and time should be entered, the person making the change should be identified, and the reason should be noted.
  • In situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected.
  • The process should permit the author of the error to identify, and time/date stamp, whether it is an error.
  • The process should offer the ability to suppress viewing of the actual error but ensure that a flag exists to notify other users of the newly corrected error.
  • The location of the error should also point to a correction. The correction may be in a different location from the error if there is narrative data entered, but there must be a mechanism to reflect the correction.

Our suggestion is that you develop a practice policy, and train your physicians and staff to ensure that your facility corrects and reports errors in a consistent and timely manner.


The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.