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Digital EditionHow to Document Adverse Medical Events: Best Practices for Protecting Patients and Providers
When an adverse event occurs in a health care setting, the moments and hours that follow are critical, not only for the patient’s continued care, but also for the physicians, practices, and hospitals involved. How the event is documented, how disclosure is handled and how the subsequent investigation is recorded can shape everything from clinical outcomes to legal exposure years down the road.
Physicians are increasingly open to disclosing adverse events to patients and families, but the documentation supporting those conversations is often inconsistent which can undermine even the best-intentioned disclosure practices, leaving providers vulnerable when memories fade and details blur.
“Documentation is essential for many reasons including patient care, and continuity of care when multiple specialties are involved. But it’s also valuable should the matter be subject to litigation,” said Tara Eichman, Senior Risk Management Consultant at ProAssurance, Part of The Doctors Company.
“Years after an event, physicians may no longer recall the details of a situation, and that makes contemporaneous documentation the most reliable record of what occurred.”
What Belongs in the Medical Record
After the patient has been stabilized, the priority following an adverse event is capturing the facts. According to Eichman, the initial documentation in the medical record should include the facts known at the time of the event, the patient’s condition and any interventions provided in response.
“This early documentation supports continuity of care for the patient and is important for downstream conversations,” she said.
Documenting the disclosure conversation itself is equally important and it’s where processes tend to differ between settings. In hospitals, an established policy typically guides disclosure, involving stakeholders such as quality, risk management, staff involved in the event, and hospital leadership. Physician practices, on the other hand, rarely have a formal process in place.
For physician practices, Eichman recommended documenting the date, time, and location of the disclosure discussion, along with the parties present and their relationship to the patient. The record should also reflect the practice’s commitment to sharing additional information as appropriate and the plan of care to assist the patient and family with any questions or ongoing needs.
Beyond logistics, the substance of the conversation matters. “Documenting adverse event disclosure involves recording a factual objective account of the conversation in the medical record,” Eichman said. That includes the patient’s understanding of the situation, any questions or concerns they raised, and the follow-up plan of care.
Tara Eichman, Senior Risk Management Consultant, ProAssurance
Timing of the disclosure conversation itself can also make a meaningful difference. “How you communicate with the patient, patient’s family, or legal guardian, and how quickly the conversation occurs can actually have a huge impact on whether the adverse event will lead to a lawsuit,” Eichman said. “When patients do not receive answers to their questions after an adverse event, they may seek litigation to find those answers.”
Her recommendation is that communication occur as soon as practical recognizing, for instance, that patient needs must be addressed before providers step away to have a conversation with family members.
What to Keep Out of the Chart
Just as important as knowing what to include is understanding what should never appear in the medical record following an adverse event.
“The medical record is not the place for speculation about what happened or statements of blame,” Eichman said. “The purpose of the medical record is to document patient care and the facts supporting that care.”
The distinction between facts and opinions comes down to objectivity. Objective facts — what happened, when it happened, the interventions that were performed — do not change over time. Subjective comments, opinions, and speculation about causation can change over time, and can complicate both patient care and any future legal proceedings.
Anything outside of objective facts should be contained in an incident report or separate from the medical record.
“The same principle applies when opportunities for improvement are identified. It is appropriate to share with the patient or family that corrective actions have been implemented to prevent similar events in the future. But the specific details of those findings should not be disclosed.”
Tools and Platforms for Documenting Investigations
Often, adverse events lead to an investigation into the circumstances surrounding the event. When an investigation takes place, careful consideration should be paid to how those materials are handled.
The tools used to document adverse events and investigations vary widely by setting. Hospitals often contract with software vendors that provide platforms designed to help quality-protect sensitive documents. Physician practices may rely on simpler systems that fit the scale of their operation.
The specific tool matters less than how it is used. “The key is ensuring that the incident information is maintained separately from the patient’s medical record,” Eichman said.
Hospital policies typically identify which stakeholders must participate in an adverse event investigation, though there is no magic number. What matters is that the investigation remains confidential and that documents produced during the process are not shared outside the investigative team. For physicians with hospital privileges, it is important to understand and follow the policies and procedures established by the hospital where they practice.
For physician practices without a formal policy, establishing a consistent internal process, one that clearly separates factual medical record documentation from investigative or subjective information, can go a long way toward protecting the practice if downstream litigation occurs.
A Foundation for Better Outcomes
Strong documentation practices may protect providers in litigation — it certainly supports better patient care, more transparent communication, and more effective patient safety improvement. As physicians grow more comfortable with disclosure, aligning documentation practices with that openness becomes increasingly important.
ProAssurance works with health care providers to help them navigate the complexities of adverse event response, from disclosure conversations to investigation documentation, offering risk management guidance tailored to both hospital and practice settings. &
