For the Record

The Effect of Documentation on Defensibility and Patient Safety

Candello’s 2024 Benchmarking Report explores the critical role documentation plays in the outcomes of malpractice cases across clinical specialties. Based on an analysis of more than 65,000 medical malpractice cases closed between 2014 and 2023, the report reveals that documentation failures contribute to nearly one in five cases. Discover key documentation risk factors and actionable best practices to strengthen your clinical documentation and mitigate risk.
             

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9 Ways to Reduce Documentation Risk
in 2025

Our data show that documentation errors persist across all specialties and care settings and double the odds of a med mal case closing with an indemnity payment. While the issue of documentation failures may seem daunting, meaningful change is within reach. To close out the year, we share these research-backed documentation tips to help strengthen defensibility and enhance patient safety.

Download our 2024 Benchmarking Report, “For the Record: The Effect of Documentation on Defensibility and Patient Safety,” for additional data and recommendations.

Here’s What Works:

  1. Recording details to support closed-loop communication
  2. Avoiding altered or late entries
  3. Not using judgmental phrasing about other providers
  4. Reviewing transcribed language before signing off
  5. Documenting informed consent conversations and the setting of patient expectations
  6. Implementing best practice solutions learned from audits and reviews
  7. Preventing inconsistent documentation to make for a stronger defense in court
  8. Noting patient non-adherence and efforts made to reach the patient
  9. Using respectful and inclusive language in the medical record
   

Inadequate Screening of Patient with Substance Use Disorder Has Fatal Ending

Case Study

A middle-aged adult with a history of depression, anxiety, and alcohol use disorder died by suicide after not receiving adequate screening, referrals, or follow-up.


Read this Case
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