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Defensible documentation: An offensive strategy

Matt Kellum (mattk@spineandsport.com) is Director of Compliance at Spine & Sport Physical Therapy in San Diego.

Here is a real scenario: You are a busy healthcare provider with a thriving outpatient practice and increasing revenue. As your caseload grows, you notice that you are falling behind on notes and not documenting as well as you did in the past. Today you receive a legal threat from a large law firm via certified mail that names you as the sole defendant in a medical malpractice suit alleging you were negligent and the direct cause of a patient needing a subsequent neck surgery after being under your care nine months prior. In between patients, you look up the patient case and see that most of the notes appear to be repetitive, contain no updated objective measures, and there are no statements in your assessments to justify continued treatment to the prescribed plan of care after you had seen this patient for four weeks. You also notice there isn’t a discharge note, and there is no record that you followed up with the patient when they simply quit coming to their appointments. Frantically you call your malpractice insurer, send them all the patient case files, and the long arduous process of litigation begins. Damian Conway summed up the importance of effective, thorough, and defensible documentation in the following quote: “Documentation is a love letter that you write to your future self.”

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