Reprinting chart pages: a liability risk?

October 21, 2005

Although I don't have an EHR, I keep a Microsoft Word file for each of my patients. I put a printout of the file in their paper chart. However, the last page changes whenever I update the document by adding a new progress note to the end. So I print out a new last page for the chart, and remove the old one, which I shred. If I were ever sued for malpractice, might this look as if I were altering patient records? Would it be better to literally cut the text out of the new printout and actually paste it into the last page of the chart?

Q: Although I don't have an EHR, I keep a Microsoft Word file for each of my patients. I put a printout of the file in their paper chart. However, the last page changes whenever I update the document by adding a new progress note to the end. So I print out a new last page for the chart, and remove the old one, which I shred. If I were ever sued for malpractice, might this look as if I were altering patient records? Would it be better to literally cut the text out of the new printout and actually paste it into the last page of the chart?

A: It's okay to continue the practice you've been using; you don't need to cut and paste. But make sure you have a written protocol that describes your charting procedures. That will help explain your actions if there's ever a question of your altering evidence in a lawsuit.