Physician Documentation Tips

Since 2010, medical documentation has been one of the most discussed topics in healthcare. Documenting patient encounters can be a painstaking process that takes lots of focus and time, but it is critical to the health of a patient, the reputation of a physician, and the success of a medical practice.

Each year, juries deliberate over thousands and thousands of malpractice cases, with the verdict often ultimately hinging on the quality and efficacy of the recorded medical documentation. When the documentation is found to be insufficient or inadequate, the likelihood of the case closing in an indemnity payment increases by 76%. And of all diagnosis-related claims made by patients, 70% are due to complications from a lack of proper medical documentation

This is all to say that medical documentation really, really matters. Below is a list of 6 ways physician can carefully increase the quality and efficacy of their medical documentation.

Recommended Reading: Tips for Efficient Medical Documentation


This one is pretty obvious, but the most important element of any recorded medical document is its accuracy. Without accurate notes, risk for a malpractice suit increases dramatically. Obviously, it’s important to be accurate when documenting a patient encounter, but that process can be mitigated significantly with as little as a recording device or transcriptionist.

Where accuracy shortcomings really hurt physicians is during the process of medical coding for health insurance providers. Studies have found that nearly one third of patient visits are under-coded, a mistake that costs providers millions of dollars each year. Additionally, medical billing errors cost the healthcare industry as a whole north of $60 billion each year.

Most clinical documentation improvement (CDI) practices heavily emphasize the importance of correct medical coding. Strictly following ICD-10 codes and learning from coding tip sheets can significantly reduce coding errors, related fees, and malpractice lawsuits.

Keep in mind that the WHO and the ICD are set to release the 11th revision (ICD-11) in January 2022. 


Some physicians are beginning to adopt SOOOAAP notes as a more in-depth approach to medical note taking and a more secure way to reduce malpractice risk. SOOOAAP notes are organized as follows:

  • Subjective
  • Objective
  • Opinion
  • Options
  • Advice
  • Agreed Plan

Documenting these explicit conversations and agreements between provider and patient is a more involved process than a traditional SOAP note, but it significantly reduces the legal risk due to improved patient understanding of likely outcomes.

Recommended Reading: You’ve Been Served: Documentation Downfalls

Don’t Copy and Paste

Copy and paste EHR documentation techniques may seem like an easy way to increase documentation efficiency, but the practice poses significant risks to documentation efficacy. Copied information may leave out important details or information and may add erroneous information to the document unless completely vetted prior to integration. Additionally, copying from external sources creates validity issues, especially if the author or creator of the original source cannot be confirmed or properly scrutinized.

In a study of medical malpractice suits, juries that learned a physician used copy and paste techniques were more likely to rule in favor of the complainant, citing the copy and paste as a clear and obvious sign the physician lacked interest or didn’t care about the individual patient. 

Keep Things Relevant

Including irrelevant information can be inefficient and add extra time to your documentation process. Avoid including repetitive or known patient information that may slow you down, and especially avoid adding inappropriate information that could put you at risk of legal action.*

Produce Timely Documentation

Producing timely documentation is critical in the defense of a physician during a malpractice lawsuit. If medical documentation is recorded many days after a patient visit, then the efficacy of the defense drops dramatically. The importance of producing your notes and documentation quickly or using a medical documentation solution tool that has quick turnaround times is essential in both the efficiency and the legal protection of your practice.

Which brings us to the last point:

Find a documentation solution that works for you

There’s a host of medical documentation solutions on the market today. Whether you employ a traditional scribe, use a medical transcription service or opt for an all-encompassing documentation solution, make sure that it’s working for you and your needs.

Keep these physician documentation tips in mind as you scour the market for the right fit for you or your practice, and also consider how cost, turnaround times, and data security may impact the overall effectiveness of your choice.

Recommended Reading: Virtual Medical Scribes: The Good, the Bad, and the Ugly

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