By Greg Freeman
Executive Summary
Avoid common mistakes with clinical documentation. Improper documentation practices can make records less valuable in litigation and for other needs.
- Copy and paste is overused.
- Overdocumentation with unnecessary details can obscure critical information.
- Vague or subjective information can diminish the value of records.
Documentation is such a crucial part of risk management that there can never be enough emphasis on how to properly document and how to avoid ruining the value of clinical records if they are ever used in legal matters. Constant education for clinicians is the only way to keep documentation clear and effective.
One of the greatest threats to good documentation is the overuse and misuse of cutting and pasting, says Rachel Hold-Weiss, JD, partner with the Benesch law firm in New York. The temptation to cut and paste can be strong in situations such as home care or a skilled nursing facility, where not much changes daily, she says. But it still can produce weak documentation.
“When you look at the records, you literally are looking at what appears to be cut, copy, and paste, and then more copy and paste. It’s not like there’s something that particular day that you’re addressing. It’s just kind of like documenting only because you have to document something and it doesn’t really paint the picture of the patient and what you’re doing for that patient that day,” she says. “It doesn’t look like a good record because it’s not tailored to that patient for that particular note.”
Another common problem stems from how many electronic medical records (EMRs) have checkboxes to make life easier for documentation and provide a bit more consistency, Hold-Weiss says. The problem arises when checkboxes are often checked on things that are not applicable to the patient, such as checking male when the patient is female or checking that the patient has a feeding tube when the patient is eating a full meal, she says.
“I see it across the board — [registered nurses], [licensed practical nurses], aides — but the aides are more susceptible to the checkbox issue because they don’t have as much free flowing text to put in. Usually, it’s with more task-based roles where you have more of a checklist issue,” she says. “Nurses are the ones who are doing the day-to-day on-the-ground care, and that’s where we tend to see more of the copy and paste.”
Documentation challenges increase as clinicians take on more patients and are inundated with more and more administrative obligations, Hold-Weiss says.
“I just think people just need to figure out how to work within the constraints that they have to do the best that they can and they’re trying,” Hold-Weiss says. “But sometimes it’s just not as successful when it comes to a review or an appeal.”
But Do Not Over-Document
Another common pitfall in healthcare documentation is over-documentation, says Jonathan Feniak, JD, a lawyer in Denver. Adding unnecessary details not only takes extra time but can obscure the critical facts if the record ends up in court, he says.
For example, subjective commentary or redundant information can confuse the main narrative or create inconsistencies across records. Policies should focus on promoting concise, factual notes that stick to the essentials, Feniak advises. Every piece of documentation should have a clear purpose and be written with precision so that it stands up to scrutiny later. Staff education must include legal scenarios, Feniak says. Just telling staff what to do and not do, without any explanation of why it is important, will never be as successful as showing why proper documentation can have such a huge impact, he says.
“When healthcare providers understand how their notes could be dissected during a deposition or trial, they often realize the gravity of accurate documentation,” Feniak says. “Simple examples of what strong vs. weak documentation looks like can drive the point home. Training should also include simulations of real-life situations, like how to document a patient refusing care or clarifying unclear orders.”
Using case studies from prior legal cases can help providers learn from others’ mistakes in a way that feels practical and relatable, he says.
Certain clinician habits, like vague or subjective language, can damage the value of documentation in legal disputes, Feniak notes. Words like “appears” or “seems” introduce doubt, as they suggest uncertainty or bias. Encouraging staff to focus on objective, clear statements — detailing what they see, hear, or do — avoids this trap, he says.
For example, Feniak says that, instead of “patient seems agitated,” they should write, “patient pacing the room, raising voice, and clenching fists.” These habits of objective documentation ensure that the record reflects the care provided without interpretation gaps, he says.
High-risk areas, such as obstetrics and surgery, often attract more claims because of their inherent complexity and high emotional stakes for patients and families, so good documentation is especially important there, he says. A single omitted detail or poorly worded entry can give rise to legal vulnerabilities, especially in cases where outcomes are life-altering, he says.
“For instance, an incomplete surgical consent form or failure to note a patient’s expressed concerns can become focal points in litigation,” Feniak says. “Instituting a robust review process — such as post-incident documentation checks — ensures accuracy and consistency, especially after critical events.”
Documentation spoils in legal disputes when it is altered post-incident, even if the intent was to fix a mistake, Feniak explains. Any change made after the fact, without proper tracking or notation, raises red flags for plaintiffs’ attorneys.
“This creates a perception of tampering, even if it’s not true. Emphasizing preemptive accuracy through diligent documentation and maintaining clear audit trails is vital,” he says. “An unbroken chain of trust in the records is what will protect the healthcare organization in the long run.”
Documentation policies must extend beyond generic templates, says Owen Muir, MD, a physician with Yung Sidekick, a company in Miami that provides artificial intelligence-assisted documentation services.
“In my experience, I’ve found that including mandatory fields for overlooked but critical details, like patient refusals of treatment or precise times for medication changes, reduces ambiguity,” he says. “Another game-changer is requiring a summary note after shift handovers, ensuring continuity of care and accountability.”
When training staff, Muir focuses on relatable examples, including anonymized legal cases where poor documentation led to malpractice suits.
“Seeing how a missing detail, like not noting a patient’s allergy reaction, played out in court sticks with clinicians,” he says. “I also advocate for shadowing sessions, where junior staff observe senior clinicians documenting in real time, learning nuance and efficiency firsthand.”
Muir notes that the overuse of copy-pasting in EMRs can create redundancy and potential inaccuracies.
“I’ve seen cases where outdated diagnoses persisted in records, causing confusion. To counter this, I recommend flagging reused content for validation during audits,” he says. “Another subtle issue is chart fatigue at the end of long shifts, so I encourage spaced reviews rather than all-at-once documentation.”
Documentation becomes legally vulnerable when there is inconsistency across platforms, such as discrepancies between bedside notes and EMR updates, Muir says.
“I insist on a centralized documentation protocol and audit for alignment. Additionally, including ‘if-then’ statements like ‘if symptoms persist, patient advised to return’ strengthens records against litigation by showing proactive care,” he says. “Encouraging a forward-thinking approach, I suggest embedding predictive triggers into EMRs, like flagging entries missing critical fields in high-risk specialties. This simple step could revolutionize the reliability of medical records.”
Timestamps Are Important
Doris Dike, JD, an attorney with the Dike Law Group in Frisco, TX, advises nurses and mid-level medical professionals to record all their movements with the aid of a timestamp.
“For instance, nurses should document who they touched as well as what they did and when. I had a nurse client who shared a nursing station on a shift with several other nurses. During her shift, a patient’s dosage was mismanaged,” she says. “My client became the fall guy because she couldn’t produce proof that she didn’t dispense the medication to that patient, although she said she did not dispense it. So, moral of the story here is that medical professionals must document all their activity and movement during their shift to protect themselves from a legal liability.”
If a doctor is providing supervision to mid-level practitioners, such as nurses and physician assistants, that doctor should provide a thorough supervision plan on who is held accountable if the plan is not executed and followed through on, Dike says. The supervision plan should further include notes on how the doctor is evaluating nurses and support staff. Doctors must have detailed notes in the patient’s charts following a patient encounter, she says. Every aspect of the exam must be documented. If an aspect of an exam was left off the charts, or a piece of medical advice left off the charts, then that missing information could open the door to a malpractice suit, Dike says. Therefore, doctors must document everything done during the patient encounter in the patient’s charts. In a legal dispute, document spoilage can fuel a malpractice charge. If there are incomplete notes in the patient’s charts, that will open a provider to a malpractice suit, Dike says.
“My best piece of advice is for providers to perform complete exams and document everything done on the patient in the patient’s charts. The provider must make sure to do a thorough exam and document that completely in the charts,” she says. “As a healthcare attorney, I have at times met patients who wanted to file a malpractice suit against their doctor because they felt the doctor did not do a detailed evaluation, rushed through the exam, and missed something on the patient.”
Definable policies and processes underly robust documentation, says Kevin Huffman, DO, a bariatric physician in Elyria, OH. His practice has created a detailed documentation guide outlining the specifics of how they document patient experiences.
“This includes things such as symptoms, medication modifications, and diet. We regularly train our staff and clinicians on these protocols through workshops and online resources,” he says. “We also allow the staff to speak directly to management on any question or issue that may arise regarding the documentation process.”
Uncompleted or incorrect documentation is one of the biggest risks, Huffman says. Huffman’s practice encourages time-tagged reports, objective monitoring, and open discussions about treatment strategies.
“Bariatric and diabetic treatments involving a tangled web of diet, medications, and surgery is one area where transparency is critical. We strive to maintain best practices so we can avoid confusion and give our patients the best care possible,” he says. “Our insistence on documentation builds trust, safeguards patients and providers, and ultimately helps people take charge of their weight-loss journeys.”
Common Pitfalls to Avoid
David N. Vozza, JD, an attorney with Norris McLaughlin in New York offers these common pitfalls to watch out for with clinical documentation:
- Incomplete or “cloned” records. Failing to document all services provided, patient interactions, or changes in patient condition can lead to disruptions in patients’ continuity of care. Comprehensive records are necessary to support the treatment decisions made and to provide future practitioners involved in the patient’s care with the accurate historical context.
- Inaccurate information. Errors in documentation, such as incorrect dates, times, or patient identifiers, can result in complaints to a disciplinary agency or the Office of Civil Rights.
- Timeliness. New York state law mandates that documentation must be contemporaneous with the date the services were provided.
- Documentation should be factual and avoid personal opinions or biases. Subjective comments can undermine the credibility of the record and expose practitioners involved in the patient’s care to malpractice claims.
Vozza says documentation can become spoiled or lose its value in a legal dispute in these ways:
- Alterations. Any deliberate change to a record is viewed as tampering, an egregious violation that can expose the practitioner to license revocation.
- Lack of authentication. Records need to be properly signed by the practitioner and indicate which clinicians were involved in the patient’s care.
- Missing documentation. Standard elements of care or patient interactions must be recorded, including review of systems, history, treatment plan, and findings.
Risk managers can help improve documentation by watching for certain behaviors, such as cutting corners, Vozza says. Clinicians should take the appropriate time necessary to properly document the indication for any service provided and reflect what transpired. Taking shortcuts, such as cloning notes, leaves the practice vulnerable to future claims, he says.
Establishing precise, uniform documentation guidelines that specify what makes for fast, accurate, and comprehensive records is essential for healthcare institutions, says Dioselvi Lora, a certified paralegal at Freedland Harwin Valori Gander in Ft. Lauderdale, FL. Staff members should get regular updates on these regulations, and training should highlight the documentation’s legal ramifications, she says. Clinicians must understand that it is crucial to document in real-time, avoid making assumptions, and give clear context for clinical judgments because ambiguous or incomplete notes can seriously impair their defense in the event of a legal dispute, she says.
“In my experience, common pitfalls include insufficient detail in documentation, which can leave room for ambiguity in legal proceedings, and delayed entries that result in missing or misrepresented information. Clinicians should be encouraged to document thoroughly during or immediately after patient interactions to ensure that no vital details are overlooked,” she says. “Additionally, relying on shorthand or subjective language can be risky, as it may be easily misinterpreted. Regular audits of medical records are essential to identify potential issues early, helping to maintain the integrity of the documentation process.”
Certain high-risk areas, such as emergency care, obstetrics, and surgery, tend to face more documentation challenges due to the fast-paced and high-pressure nature of these specialties, Lora says. In these areas, it is crucial to document not only the actions taken but also the reasoning behind each clinical decision. Using structured documentation processes, like EMR templates or checklists, can ensure all necessary information is captured consistently.
“By creating a culture of careful, precise documentation and providing ongoing training, healthcare organizations can reduce the risk of documentation errors and improve their defense if legal challenges arise,” she says.
Effective documentation is especially crucial in specialized healthcare areas like hair restoration, says Michael May, MD, medical director at Wimpole Clinic in London, England. Policies and procedures should start with clear documentation protocols tailored to your field, he says.
“In hair restoration, for example, we ensure every patient interaction — from consultations to post-procedure follow-ups — is recorded with timestamps, detailed observations, and consistent terminology,” he says. “This minimizes ambiguity and ensures continuity of care.”
Staff training is non-negotiable, May says. Regular workshops on proper documentation practices, emphasizing real-world examples, help reinforce the importance of precision, he says. For instance, documenting patient consent in hair transplant procedures, along with photos, ensures transparency and safeguards both parties, he says.
“Errors often stem from incomplete or inconsistent records. You need to include details or rely on memory to maintain the credibility of your notes in a legal dispute,” May says. “Another common mistake is failing to update records promptly. Delayed entries raise questions about authenticity, which can weaken your case if documentation is ever challenged.”
Clinicians sometimes fall into routines that unintentionally undermine documentation quality, May says. Over-reliance on templates or generic language is one example.
With high-visibility specialties, including cosmetic and elective procedures, discrepancies between patient expectations and outcomes frequently lead to claims, May says. To mitigate this, ensure detailed records of patient discussions about realistic outcomes and risks are supported by visual evidence where appropriate, he says.
Leaders should foster a culture of accountability for documentation, May says. Periodic audits can identify gaps and reinforce best practices.
“Ultimately, documentation is as much about protecting the patient as it is about safeguarding the clinic,” he says. “It builds trust, reduces liability, and improves care when done right.”
Sources
- Doris Dike, JD, Attorney, Dike Law Group, Frisco, TX. Telephone: (972) 290-1031.
- Jonathan Feniak, JD, Denver. Email: [email protected].
- Kevin Huffman, DO, Elyria, OH. Email: [email protected].
- Rachel Hold-Weiss, JD, Partner, Benesch, New York. Telephone: (646) 777-0024. Email: [email protected].
- Dioselvi Lora, Freedland Harwin Valori Gander, Ft. Lauderdale, FL. Telephone: (954) 467-6400.
- Michael May, MD, Medical Director, Wimpole Clinic London, England. Email: [email protected].
- Owen Muir, MD, Yung Sidekick, Miami
- David N. Vozza, JD, Norris McLaughlin, New York. Telephone: (917) 369-8867. Email: [email protected].
Greg Freeman has worked with Relias Media and its predecessor companies since 1989, moving from assistant staff writer to executive editor before becoming a freelance writer. He has been the editor of Healthcare Risk Management since 1992 and provides research and content for other Relias Media products. In addition to his work with Relias Media, Greg provides other freelance writing services and is the author of seven narrative nonfiction books on wartime experiences and other historical events.
Documentation is such a crucial part of risk management that there can never be enough emphasis on how to properly document and how to avoid ruining the value of clinical records if they are ever used in legal matters. Constant education for clinicians is the only way to keep documentation clear and effective.
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