Winning the Race Before it Starts: Documentation that Holds up in Court
With the Bluegrass racing season in full swing, from Keeneland to the Kentucky Derby, everyone is looking to make smart bets and come out ahead. Some study the contenders for weeks before making their picks; others go with a gut instinct, choosing based on horse names, coat color, or even the jockey silks.
But what about the bets you are making professionally? Are you setting yourself up to win?
No one expects to end up in a lawsuit, just like no one expects for the race day favorite to finish dead last. But when something unexpected happens, preparation matters. In the medical profession, your best safeguard is not luck, it is documentation. Accurate, thorough, and clear records ensure that if your decisions are ever questioned, you can justify every call you made.
At its most basic level, a medical malpractice claim is a specialized negligence claim. The plaintiff has the burden to prove the healthcare provider deviated from the applicable standard of care and that the deviation resulted in the plaintiff’s injury.
However, unlike an ordinary negligence case, medical malpractice claims often require an extra step before the plaintiff can even file their lawsuit. In most jurisdictions, including Kentucky, the plaintiff must have a qualified medical expert certify that the claim has merit. This requirement serves to help prevent groundless lawsuits.
Therefore, a patient’s ability to bring a lawsuit against you or your practice often depends on another medical professional reviewing your care and attesting that, in their expert opinion, you fell below the applicable standard of care.
They will review the patient’s medical history, presenting symptoms, and the medical records you authored in connection with your evaluation and treatment. They will look for weaknesses or ambiguities in your case, your documentation, and your clinical decision-making to cast doubt on the level of care you provided on a particular date or over a period of time.
For that reason, it is imperative that you make a “smart bet” on yourself by ensuring records clearly reflect the reasoning behind your medical decision making. In many cases, it becomes your word against someone else’s.
This is why documentation is critical. Your documentation, if completed with awareness of medical malpractice lawsuits, will support your recollection of events and help bolster your credibility. Make it difficult for others to question the care you provided!
Below is a non-exhaustive list from the perspective of a medical malpractice defense attorney, outlining steps you can take now to strengthen your position should you ever face a claim. At the end of the day, you strive to provide the best care possible for all your patients, and proper documentation helps ensure you can prove it.
Include personal details or observations: Did your patient mention an upcoming vacation? Did they just beat their personal best on the golf course? Or share what their book club is reading this month? These details may seem insignificant or too time-consuming to include in the medical record, but small personal touches can demonstrate the depth of your interaction with the patient. It can also help you recall the patient months down the road. Including this level of detail proves that your encounter went beyond a routine, checkbox-style visit and reflects a more meaningful, attentive interaction.
Beware of template or auto-generated text: Many charting systems allow auto-generated test to be inserted into a patient’s medical record based on the diagnosis. This can be efficient and reliable when used correctly, but it does not reflect your independent thought process. The program did not evaluate the patient, you did. Templates can be a helpful starting point, but they should not be the final product. You should always review and add additional information to reflect the history you gathered from the patient and relied upon to make your diagnosis. While these tools can improve efficiency, unedited or inaccurate entries can undermine your credibility later if misused.
Review your charting: This may seem simple and intuitive, but mistakes are easy to make when you are pressed for time and have a full day of appointments. However, even small errors can undermine your credibility later. For example, did you treat a patient with a fractured collarbone but accidentally document their pain level as 0 out of 5? Or did you note that a patient denied headaches in your review of symptoms, when they specifically reported daily headaches during their visit? These inconsistencies can appear careless or suggest that you were not fully attentive at the time of the patient encounter. If they conflict with your ultimate diagnosis or treatment plan, a plaintiff’s expert could use them to question your clinical judgment. Careful chart review before finalizing the record helps to ensure that your documentation accurately reflects what you observed and the care you provided to the patient.
Timely charting: It is important to complete your charts as soon as possible after seeing a patient. With a full day of appointments, important details can be lost or unintentionally omitted if you wait too long to document your encounter. Timely charting helps ensure that your notes accurately reflect the care you provided. This is especially important because most electronic health record systems automatically timestamp when a record is signed. It is generally not ideal if a patient is seen on one date, but the provider does not sign the record until weeks or even a month later. Additionally, most systems also track when a chart is accessed or edited. Of course, if you later review a record and discover a genuine error or omission, it is appropriate to correct in accordance with your recollection of the encounter. However, once litigation has begun or a claim is anticipated, altering records is not advisable. This can create the appearance of improper motives, like something is being concealed.
Supervisory or consulting note: Did you consult with another physician on a patient’s case, or were you the consulting provider? If so, make that clear in the medical record and include as much detail as appropriate. Note whether your involvement was limited to a chart or medication review, or whether you personally evaluated the patient face-to-face. Clearly documenting the nature and scope of your involvement can be critical if a claim arises. If you are named in a lawsuit along with the primary treating provider, a well-documents record can help establish exactly the role you played, or lack thereof.
In this race, and the context of medical malpractice, documentation and preparation can be the difference between a last place finish and the winner’s circle. Do yourself a favor and perfect your documentation skills to save yourself from future losses!
Camille B. Camp is a healthcare law and medical negligence defense attorney with Sturgill, Turner, Barker & Moloney, PLLC. She can be reached at ccamp@sturgillturner.com or (859) 255-8581. This article is intended as a summary of state and/or federal law and does not constitute legal advice.
This article originally appeared in the Lexington Medical Society May 2026 Newsletter.
