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Document, Document, Document!

By Barry B. Cepelewicz and Gary S. Sastow

Typically, health-care providers approach documentation with the goal of effectively communicating with themselves. The reality, however, is that depending upon many different circumstances, numerous other individuals may one day review a health-care provider's records for many different purposes and from many different perspectives. Records may be reviewed by other health-care providers, billing personnel, patients, lawyers, insurance companies, governmental regulators (both federal and state) and in some instances, law-enforcement personnel.

The old adage, 'If it isn't written down, you didn't do it,' still rings very true, particularly in the medical malpractice context. The best way to counter an allegation that a provider failed to examine or check something is to point to the records that clearly demonstrate that the opposite is true. The necessity for complete, honest, accurate and legible documentation cannot be over emphasized. This being said, however, it is recognized that documenting every thought may at times be cumbersome and not altogether realistic. To make up for this practical deficiency, it is important to establish clear methods and procedures for doing business. These methods are sometimes referred to as a provider's 'standard operating procedure.' The procedures should be uniformly and consistently applied with each patient encounter.

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