Documentation: proactive prevention of litigation.

There is no quick and effective antidote to malpractice allegations. Prevention, however, is necessary.

Thorough and thoughtful documentation provides evidence against miscommunication and misunderstanding, and may help guard against a lengthy litigation process. No matter what we do or say we do, it is virtually impossible to prove unless it is clearly documented. Remember the general rule, "Not documented, not done." Moreover, documentation needs to go beyond what was actually performed, to include the thoughts, statements and intentions of both the provider and the care recipient.

The overall philosophy of care should be to listen to all concerns expressed by a patient/family/power of attorney and help those individuals engage in the decision-making process related to their care. Whether or not an individual would like to participate in primary and secondary prevention activities, have a dressing changed at one time or another, or take a walk after a surgical intervention for example, are all things that should/could be discussed with patients. Document, document and document should be the mantra around all care activities.


Techniques to avoid

Some facilities and nurses follow a documentation principal that focuses on charting by exception. That is, a care activity is assumed done unless charted otherwise. Moreover, they only encourage documentation when an unusual event or change of condition occurs. Commonly found with this philosophy of documentation is the checklist approach, which can result in quick and careless documentation. When checklists are used, it is not clear what was actually done, who did it and what contradictions in the care that occurred may arise as a result.

Another method of documentation frequently used by health care providers is the SOAP note. The SOAP note addresses subjective and objective information, and results in an assessment and plan of care. This type of documentation serves as a good template for gathering of information. However, it does not encourage or even really allow for a more proactive approach to patient care in terms of risk reduction.


SOOOAAP Documentation

An extension of the SOAP note is the SOOOAAP note. SOOOAAP selectively expands SOAP by embedding it with easy-to-remember, risk-reduction techniques. This documentation technique can help to improve communication, enhance patient care and decrease your risk of being charged with malpractice. SOOOAAP includes not only subjective and objective information but also the opinion, options, advice and agreed plan as noted by both the provider and the response of the patient and/or caregiver. This format encourages two way communication, patient participation and informed consent of the patient. Moreover, the note keeps a record of the patient's acceptance of the responsibility for following through with the health care plan.

SOOOAAP documentation changes the traditional focus of documentation to a more patient centered approach. Traditionally, health care providers have used documentation to communicate among each other. This approach creates problems when malpractice allegations are made as the providers may assume a certain type of care or care activity was done, but if it wasn't clearly documented it can appear as if there was negligence with basic care activities omitted. The SOOOAAP Explained section (below) provides a more comprehensive description of the SOOOAAP and helps to delineate the change in documentation from serving as a provider tool to one in which there is provider and patient input.

The subjective data included should be driven by patient quotes to demonstrate your attention to the patient, and it should highlight main areas of concern. Objective information should include observed events using assessment skills and appropriate diagnostic tools. Concerns related to tool validity should be indicated in the note (i.e. a questionably accurate blood pressure cuff or a poor fitting cuff). Document if a chaperone was present during an exam when sensitive procedures are being performed (i.e. breast exams). Choose your words carefully and avoid judgmental or potentially anger-provoking descriptors of individuals.

The opinion section is similar to assessment but is more comprehensive in that it reviews the data that supports your assessment and provides a rationale for care decisions and recommendations. It is appropriate to let patients and families know that the diagnosis may not be definitive, but that it is a work in progress. You may think the pain, for example, is normal related to a surgical intervention, but you inform the patient that you will give an appropriate dose of pain medication and re-evaluate in 1 hour. Following opinion, the options of care should be delineated and there should be documentation that the patient has agreed or disagreed with what you have said. In cases where a patient refuses treatment, document that he or she understands the implications of refusal.

The next section of your note should focus on your advice to the patient. This is where the provider has the opportunity to share expertise and help guide the patient's choice. Document your reinforcement of the principal that you are providing information and advice, and allowing and encouraging the patient to make his or her own decision about care. Continually document health promotion recommendations and prevention techniques (i.e. smoking cessation and exercise), whether or not these are related to the presenting problem. This provides evidence of your concern and interest in the whole person.

Finally, document the plan that has been agreed upon between you and your patient. For example, indicate that the patient/provider interaction resulted in a decision to recheck blood pressure tomorrow and then refer for further treatment if the blood pressure is still high. Indicate if the patient understands and agrees with the plan. When medications are prescribed, document that the patient has been instructed on use of the drug and he/she has provided evidence of understanding of the medication treatment plan.

Successful clinical care is a collaborative effort with the provider and the patient. Documentation should reflect this shared effort. Using the SOOOAP technique will facilitate this philosophy of care and provide an avenue to comprehensively demonstrate that it was done. In so doing, health care providers will be proactively protecting themselves and patients from the trauma of care interactions that can result in litigation.

SOOOAAP Explained

S: Subjective

Use patient's words to provide indication of their attitude. Should include a complete review of systems and inclusion of additional concerns that were not the primary reason for seeking care.

O: Objective

Should be measurable, reproducible data including things like recent lab tests or imaging. All physical exam findings and any concerns about faulty equipment or inability of patient to fully perform test.

O: Opinion

This is similar to assessment but further explains that there may be limitations to your assessment-that the final assessment is still ongoing should be made clear.

O: Options

Documents information provided to patients, whether or not this is evidence based recommendations or routine practice, and what the treatment side effects might be and what would be the result of no treatment.

A: Advice

The is the recommended best choice by the health care provider with a rational for your recommendation. "…If it was my mother…based on what you know. "Health promotion activities and recommendations would be documented here.

A: Agreed

Plan pulls discussion together and states what patient has agreed to follow or what he/she makes an informed decision not to do.


Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

See more FAQs

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