At Your Service
Careful Documentation Is Best Protection
Psychiatric News
Volume 42 Number 8 page 40-40

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" record.

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 criminal act.

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 Convention Center:

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 TheProgram@prms.com.

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