Q. I do my best to document scrupulously in patient charts, and after
attending a recent risk management seminar, I have recommitted myself to
documenting as thoroughly as I am able. I wonder, though, is it possible to
create a perfect treatment record? I understand the risk management advice
related to documentation, but at times it becomes unrealistic. There is just
not enough time in the day!
A. First of all, take comfort in the fact that there is no such
thing as a perfect record. Rather, the record should be "good
enough." What does that mean? While the specific content of a
psychiatric record may vary, the purpose of documentation remains
constant. A good record accomplishes several things: it substantiates your
clinical judgment and choices, demonstrates the knowledge and skill you
exercised during treatment, provides a contemporaneous assessment of the
patient's needs and behaviors, and documents significant events, revisions to
the treatment plan, and explanations of your decisions.
Also, you do not need a "perfect record" to win a lawsuit, but
you do need one that is "good enough." It is true that
documentation plays a vital role in the defense of a malpractice lawsuit;
without adequate documentation it may be very difficult to demonstrate that
you provided appropriate care. However, an experienced defense attorney can
work well with a cooperative clinician and a "good enough"
You should not become complacent. The reality that perfection can never be
obtained should not prevent you from striving to create as complete and
supportive a record as possible.
There is one absolute with regard to records and professional liability:
never alter a record. Altering a record destroys your credibility in
a lawsuit, could compromise your professional liability insurance coverage,
could lead to sanctions from your medical-licensing body, and will impact your
professional reputation. In addition, altering a record may be considered a
Q. Will the Psychiatrists' Program have customer-service staff at next
month's APA annual meeting in San Diego, and will staff be presenting at any
risk management or insurance sessions?
A. Yes. The Psychiatrists' Program will be located at booth #802 in
the Exhibit Hall. PRMS, the manager of the Psychiatrists' Program, will have
risk managers and insurance underwriting specialists present to provide
individualized insurance information and risk management advice for
psychiatrists. Complimentary risk management articles and information about
future seminars will also be available.
If you are a participant of the Psychiatrists' Program, be sure to stop by
and receive complimentary copies of the most-requested materials as a
thank-you for your participation. You will also receive a complimentary"
For Participants Only" customer resource guide.
PRMS staff will be presenting at the following sessions in the San Diego
While at the meeting, be sure to check the conference schedule for
last-minute changes to times or locations.
This column is provided by PRMS, manager of the Psychiatrists'
Program, for the benefit of APA members. More information about the Program is
available by visiting its Web site at<www.psychprogram.com>;
calling (800) 245-3333, ext. 389; or sending an e-mail to