The best offense is often a strong defense—especially when it comes to successfully defending healthcare providers in medical malpractice cases. One way to build a defense in medically-related lawsuits is by demonstrating that the healthcare company being sued met the standard for quality of care.

There are many aspects to building a strong defense, but one crucial factor is using the medical record to paint a picture of the quality of care that was provided. In many cases, the medical record contains much of the information the defense needs. The trick is knowing how to navigate the complexities of the medical record.

Some medical record experts use a five-step process to assess quality of care in medical defense cases, which often involve issues such as infections, pressure injuries, and falls. The steps of the process may not always be linear, but the approach typically includes assessment, diagnosis, planning, implementing and evaluating.

1. Assessment – The first step is often checking to see whether the facility gathered assessment data about the resident from available sources, such as a health history, physical examination, observation, diagnostic tests, and patient/family interaction and communication. Take the common issue of falls as an example: An older adult’s fall risk must be assessed and documented upon admission or readmission into a facility, and reassessed after every fall. Even without falls, the facility should perform assessments on a regular—typically quarterly—basis. Determine whether the facility relied too much on standard forms that assign fall risk scores, or if they provided their own analysis based on individual risk factors and variables.

2. Diagnosis – Become familiar with the facility’s process for taking assessment data and turning it into an informed diagnosis of actual or potential health problems. A successful defense may depend on showing that the facility took the data and used it for care planning and decision making. Also, developing a complete diagnostic picture of the resident will depend on more than just admission assessment data. The medical record will provide insight to not only the admission assessment and diagnostic information but whether the facility continued to gather data and update its diagnoses throughout the admission, depending upon patient activity and behavior.

3. Planning – Analyze the record to determine whether the facility developed a clear, measurable goal plan and corresponding interventions. This may include assessing whether the healthcare provider adjusted the environment to the patient’s specific needs. For falls, this may include considerations relating to lighting, grab bars, and equipment that functions properly, as well as daily interventions such as making sure pathways are clear and quickly eliminating safety hazards from spills or other accidents. Planning essentially comes down to knowing the patient and their individual needs and making necessary adjustments when there is any type of change in status.

4. Implementing – The next step is to evaluate medical record information to determine what the facility did to effectively carry out the planned interventions. When it comes to falls, this generally begins with the fall risk assessment and any other relevant information about the person and their level of functioning. Then it will be necessary to determine if the facility created an individualized care plan that took reasonable steps to decrease fall risk. Standard implementations may include installing side rails on beds; monitoring bathroom trips and providing toileting assistance; and positioning people with higher fall risk closer to nursing stations where staff are more likely to be in proximity. Similarly, the facility may group residents who are at a fall risk in the same area and assign more aides to that area. Look for examples of the care team demonstrating its knowledge of the residents and their patterns.

5. Evaluating – Finally it is essential to determine if caregivers documented whether patient care planning goals were met. It should be evident that the facility restarted the process in the event goals were not met or the patient or resident did not improve. When falls happen, generally there is a reason—and the next step is to figure out the cause of the fall. It is a red flag if the medical record notes that the resident fell, and the facility continued with the same interventions. In contrast, look for instances where a resident fell and the care team took steps to improve its care plan and develop new interventions.

Other considerations when assessing a medical record include analyzing it for completeness and legibility, or whether it’s missing information that might be relevant to determining the quality of care provided. Additionally, look for timeliness in terms of assessment and care documentation being performed as completed, rather than sometime after the fact.

Ultimately, achieving quality of care standards requires a multidisciplinary approach and a lot of communication—a true team effort that may include not just nurses and CNAs, but also therapists and housekeeping staff. This information can typically all be found in the medical record.

Need assistance with assessing a medical record for a medical malpractice defense? Our experts can help.