Employers Pay a Price for Improper Medical Documentation
By Jennifer Phillips, Manager, Workers’ Compensation, Pitney Bowes
When faced with litigation, employers can support decisions about leaves of absence through detailed and complete case management documentation that is based on a thorough analysis of comprehensive data. However, many integrated absence management teams that are responsible for keeping official notes on employee medical files lack formal training in proper documentation protocols. While nurses often receive some instruction on documentation techniques in nursing school, not all case managers are nurses. And since case management notes can be subject to audit, subpoena, and legal scrutiny, missing details can pose a legal and financial risk to employers. In fact, improper medical documentation increased average litigation expenses by $2,658 per claim, according to the Nurses Service Organization (NSO).1
To mitigate that risk, formal training should differentiate objective and subjective information and it should describe how to document assessment and intake findings, create a detailed action plan, and explain why a decision is in line with disability plan terms. Any deviation from disability plan terms in the notes can set a precedent and support the argument that if an employer made an exception in the past, it should make the exception again. Situations like these can lead to loss of credibility. In fact, sufficient documentation has been cited by legal experts as “the foundation of any good defense of an employment practices claim.”2
If case managers do not apply disability plan terms consistently and document their approach adequately, the notes will not be helpful in mitigating additional liability exposure. Clear, concise, accurate, consistent, and objective case management documentation is crucial to reduce employer liability. Here are five key questions claims managers should consider:
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