Why Documentation is a Crucial Aspect of Disclosing an Unanticipated Outcome

Documentation is essential in chiropractic care for many reasons. It memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides useful data for quality improvement, and may provide critical information in the defense of a malpractice lawsuit. Documentation also serves a crucial role in the disclosure of unanticipated outcomes or adverse events, such as errors, mismanagement, system errors, or other unforeseen situations that may lead to patient harm.

As part of the disclosure process, an appropriate member of the chiropractic team should document the unanticipated outcome in the patient’s health record, including an objective summary of the pertinent facts surrounding the event. These findings might include the patient’s condition immediately before and after the event, subsequent treatment, and the patient’s response to treatment. 

The disclosure conversation should also be documented in the patient’s health record, including:

• Time, date, and place that the conversation occurs
• The information that is communicated to the patient/family
• The patient’s/family’s understanding, any questions they ask or information they want clarified, and any responses provided
• Names of those present for the disclosure conversation, and who will be responsible for follow-up communication with the patient/family
• Next steps for patient treatment, care, and communication
• A notation that disclosure was based on information available at the time of the conversation with the patient/family

Documentation should be completed as soon as possible following the unanticipated outcome and updated accordingly as new information becomes available. This is a necessary part of a chiropractic practice’s overall risk management strategy.

When it comes to effective communication after an adverse outcome, consulting with your professional liability company’s risk management team is always a good idea. Before making expressions of sympathy or having disclosure discussions, contact your risk consultant to walk through the situation. It may keep you from a malpractice suit and ultimately lead to a better patient relationship.

To learn more about the disclosure process, see ChiroPreferred by MedPro’s guideline and checklist about disclosure. For more strategies related to documentation, take advantage of two free MedPro checklists: Documentation Essentials and Electronic Documentation.