Missing Documentation
Legal nurse consultants receive medical records from healthcare providers, either through working as an employee in a law firm, insurance company or being an independent consultant.
If we want full certified records we trust that the facility will send them. The attorney relies on us to recognize if there is missing documentation. We don’t always get full records or pages are missing. Spotting missing sections of medical records is easy if you use an organized approach to reviewing medical records. What is harder is detecting information that should have been charted and was not.
Missing documentation
You are reviewing a medical record and find that there is no documentation that describes what a healthcare provider did. What are some possible explanations?
Attorneys like to use the phrase “If you didn’t chart it, you didn’t do it” to focus on missing documentation. There may be other explanations.
The care in question may be documented by someone else in the medical record.
Solution: Carefully review the medical record to see if the care is referenced by another provider or if orders were written based on the care. Sometimes a timeline helps to more clearly define the details. Look at the medical records of other providers, such as consultants who may have received portions of the medical record from another provider.
The care was not done.
The provider cannot effectively assert that he or she did something in the absence of any documentation that verifies that it was done.
Solution: Look at the implications of the absence of care. Does it affect liability? Does it affect damages? Does it affect causation? Does it make a difference in the case?
The page describing the care was not supplied by the medical records department or healthcare provider.
Solution: Ask for a certified copy. Look at the original if necessary. Consider the possibility that the page describing the care was removed from the medical record in a deliberate effort to tamper with medical records.
Care may have been done but the provider forgot to chart it, was too busy or distracted.
Solution: Ask the provider if he or she has any memory of doing it. Recognize that memories are flawed or may be influenced by self-serving needs. The provider will assert that although it was not charted, it was his customary practice to do a specific thing. We know as nurses that it is not possible to document every single element of care.
Missing documentation may have profoundly affect on a case. Use your knowledge of medical records to spot missing documentation and raise questions about their implications.
Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. She has heard, “If you didn’t chart it, you didn’t do it” for 25 years. Few phrases make nurses cringe more. Learn more about spotting missing records and the three other top medical record traps by getting the digital download of an all new webinar, Medical Record Traps and How to Overcome Them.