Self-Audit: How Would Your Records Hold Up in Court?

Try this as a way of assessing the adequacy of your own patient records. Pull an “inactive” record from your files (i.e., someone you haven’t seen in 3 years or more). Look through it.

– Do your notes bring to mind the patient?
– Do you understand what you were doing with that patient, in terms of general medical history, your diagnosis, your treatment plan at the time, and  the course of the treatment?
– Are there any parts of the record you cannot understand, either due to illegible handwriting or unexplained drastic changes in your treatment?
– Are there any records of phone calls?

Of course, don’t change anything in the record. Put it back in the file, just the way you found it. But ask yourself, if I received a letter from a lawyer or from the state licensure board today about this patient, would I have any idea what was going on with this patient three years ago? Keep in mind that rarely does a patient sue immediately.  In malpractice litigation or in defending your license, you are often testifying to events that transpired years before.  Will your records help you, or leave you clueless?

The President’s Column is written by PRMS CEO and President Martin G. Tracy, JD, ARM, and addresses important topics and trends in psychiatric risk management.


Categories: PRMS Blog, Documentation