Physicians and other medical professionals are likely familiar with colloquialisms about the importance of medical documentation, especially in how it can influence liability claims.
- “Medical documentation is the memorialization of real-time discussions between doctor and patient.”
- “Years later, the only reality that matters is what you documented.”
- …and the ever-popular, “If it wasn’t documented, it didn’t happen.”
But, how much does the quality of documentation actually impact the outcome of medical malpractice cases?
The 2024 Benchmarking report from Candello1, a national data collaborative of medical professional liability insurers and health systems conducted a deep dive into over 65,000 cases closed between 2014 and 2023 to determine the degree to which improvements in medical documentation can enhance patient safety, fortify legal defenses, and contribute to a culture of precision and accountability.
Their analysis revealed that 20% of cases filed involved at least one instance of documentation failure. They further found that the likelihood of an indemnity payment upon case closure more than doubled when documentation issues contributed. Additionally, they noted a correlation between cases where documentation was at issue and those involving severe patient injury or death.
Even in claims closed without a settlement or judgment paid, documentation cases took longer to resolve and resulted in substantially higher defense costs. All of these factors contribute to increased indemnity and expense payments which ultimately translate to higher costs to obtain coverage.
In looking at specialties where claims were most impacted by documentation factors, the authors considered both the number and proportion of claims containing record-keeping contentions and those where resulting indemnity costs were disproportionately high. The specific aspects of documentation producing defense challenges varied according to the service bearing primary responsibility for the care at issue.
- In surgical cases informed consent was a chief concern. Patients often claim they did not receive all relevant information needed to fully comprehend risks, that they were not adequately informed of alternatives, or that expectations for outcomes were trivialized. Inadequate reporting of clinical findings often led to a lack of clinical basis to support care or treatment decisions as well as poor planning and adherence to follow-up. Additionally, undocumented counts of surgical instruments and supplies can be a critical factor in claims involving retained foreign objects.
- Among primarily medical cases, failure to follow up on abnormal diagnostic results was a primary factor in missed or delayed diagnosis and treatment. This was the result of both inadequate provider communication as well as patient misunderstanding of implications. Clear records of discussion regarding abnormal findings and instructions for next steps in care delivery are crucial.
- Gaps in details surrounding procedures such as cardiac catheterization and endoscopic examination create openings for allegations of technical error.
Documentation of complications related to known risks, steps taken to mitigate or prevent their consequences, relevant conversations between care team members, and disclosure all contribute to lasting illustration of clinician diligence. Thorough explanations of shared clinical decision-making and discussions around managing medication interventions, likewise help to reconcile criticisms of clinician responses to sub-optimal therapeutic results.
While fewer cases were filed against them, the financial and clinical tolls of gaps in documentation were exaggerated in certain specialties. Among them OB/GYN claims are often amplified by documentation issues intersecting with devastating emotional circumstances. In anesthesiology, where documentation methods and technology vary widely, both clinical severity and economic losses can easily double when records are incomplete or unclear. And in the fast-paced and high-pressure environment of emergency medicine, diagnostic errors are vastly more common in the medical record leading to outsized total settlements.
Technological advancements and evolution of the capture of medical recordkeeping can be useful in streamlining the translation from care delivery to digital history. Both novel and legacy pitfalls remain, however.
- “Copy and paste” continues to haunt defense teams and increases the likelihood of money changing hands by nearly 80%.
- The use of scribes and AI transcription, while often helpful, still require diligent review and proofreading to ensure that they enhance, rather than replace, judgment and attention to detail.
- Templating notes, the informal nature of text messaging, and patient access to clinicians and records via portals all conceal vulnerabilities ripe for misunderstanding and legal exploitation.
Conclusion
Most liability claims are not brought based primarily on documentation lapses. Nevertheless, the quality and reliability of medical documentation can make a significant difference in the outcome of a medical liability case. Candello Vice President, Michael Paskavitz stated, “Our data illuminate how a documentation error can make a case go from unlikely to likely to close with an indemnity payment.”
The report lists a number of actionable insights to optimize effective clinical documentation:
- Avoid inconsistencies or omissions in documentation. Details matter.
- Document your clinical rationale.
- Clearly and accurately document the informed consent process.
- Reduce or eliminate copy and paste. Always follow organizational guidelines for citation and chronological references.
- Document non-adherence including plans and timeline for follow-up.
- Avoid stigmatizing comments or language.
- Do not criticize other providers—sometimes referred to as jousting.
- Do not alter medical records. Untimely entries—especially after an adverse event or outcome— can arouse speculation.
The report's authors also reinforce the importance of learning from audits and reviews. Copic Safety and Risk Strategy reviews offer useful tips for reducing risk from problematic documentation practices. For guidance contact the Patient Safety and Risk Management team.
1 Ringler C, Roberts A, Babayan A, Luu P, Tremetn H (ed). For the Record: The Effect of Documentation on Defensibility and Patient Safety; CRICO (Candello); 2024. www.candello.com
The information provided herein does not, and is not intended to, constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.
Article originally published in 2Q25 Copiscope.
