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BUSINESS OF
MEDICINE

The Role of Documentation

In Diagnosis-Related Malpractice Allegations

By Laura M. Cascella, MA

Allegations associated with diagnostic errors — i.e., wrong diagnoses, delayed diagnoses, and missed diagnoses
— are a top cause of malpractice lawsuits. A number of risk factors can lead to diagnostic errors, including
issues related to documentation of clinical care.
MedPro Group’s closed claims data from 2007 to 2016 show that documentation issues occur in almost 1
in 5 diagnosis-related claims. These issues generally fall into three categories: (1) insufficient/lack of docu-
mentation, (2) content, and (3) mechanics.

Documentation as a Contributing Factor in Diagnosis-Related Claims

Source: MedPro Group closed claims, 2007-2016

When it comes to defending malpractice claims, accurate and lead to documentation deficits include:
thorough documentation of the provision of clinical care is crucial. • Failure to document attempts to follow up with a patient about
Thus, understanding the types of documentation missteps that con- care or test results.
tribute to diagnostic errors can help healthcare providers assess their • Failure of the healthcare provider to document that he/she has
current processes and adjust as necessary to reduce liability. been involved in a patient’s care.
• Missing documentation in the patient’s record (e.g., patient
Insufficient/lack of documentation problem list, test results, consultations, referrals, signatures in-
Among the categories represented in the previous graph, insuf- dicating review, or medication lists).
ficient documentation dominates. Examples of situations that can • Failure to document adequate details about the patient en-

26 San Antonio Medicine • June 2018