The ongoing murder trial of Lindsay Clancy in Massachusetts is an extraordinary case involving an unimaginable tragedy. For psychiatrists and other behavioral health providers, however, the testimony also provides a rare look at what happens when routine clinical decisions are revisited years later in a courtroom, after the outcome is known and with every aspect of the treatment record available for examination.

Recent testimony has focused extensively on the psychiatric treatment Clancy received before the deaths of her three children, including treatment provided through telemedicine. During cross-examination, the defense questioned her treating psychiatrist about medication decisions, the length and format of video appointments, what she was able to observe remotely, whether she had access to other treatment records, whether an in-person assessment should have occurred, and what she documented during those encounters. Watching that testimony is a reminder of a difficult reality for physicians: clinical decisions are made in real time, based on the patient’s presentation and the information available at that particular moment, but those same decisions may later be examined by lawyers and experts who know what happened next.

This is particularly relevant to telemedicine. Virtual care has dramatically expanded access to psychiatric and behavioral health services and, for many patients, is entirely appropriate. At the same time, every practice providing care remotely needs a workable process for recognizing when the limitations of telemedicine become clinically significant. There will be circumstances in which a patient should be evaluated in person, referred for emergency assessment, or moved to a higher level of care. There will also be many situations in which the provider reasonably concludes that continued treatment through telemedicine remains appropriate. The important issue from a risk-management perspective is whether the record allows someone reviewing the encounter later to understand what the provider observed and why the chosen course of care was reasonable at the time.

That issue came into focus during the Clancy testimony when the defense questioned the psychiatrist about why Clancy was not evaluated in person. The psychiatrist testified that she did not believe the video format prevented her from adequately assessing her patient. Whether that clinical judgment was correct is not the lesson healthcare providers should take from the case, and it would be unfair to suggest that physicians should somehow be able to anticipate catastrophic events that may occur later. What the testimony does illustrate is how a decision that may have been entirely ordinary during the course of treatment can become enormously important when examined retrospectively. If the appropriateness of telemedicine is later challenged, the medical record may be the best evidence of what the provider actually knew, observed, considered, and decided at the time.

Another exchange during the trial illustrates the problem even more simply. The defense questioned the psychiatrist about a handwritten note describing Clancy’s speech. The psychiatrist acknowledged that the wording did not accurately convey what she intended and explained that she knew what she meant when she wrote it. Any busy clinician can understand how that happens. Medical records are written in the middle of clinical practice, often between patients and under considerable time pressure. Shorthand, templates and abbreviated descriptions may make perfect sense when the encounter is fresh. Years later, however, the person reading the note may be a malpractice attorney, expert witness, licensing investigator or regulator who has no access to what the provider intended to say. That person has the words on the page.

The same problem arises when an important clinical consideration is not documented at all. A provider may have considered whether an in-person evaluation was necessary, discussed worsening symptoms, reviewed available records, or considered escalation to a higher level of care and reasonably decided against it. If the chart contains no indication of that thought process, the provider may later be asked to reconstruct it from memory. That becomes considerably more difficult several years later and after a serious adverse event has changed the context in which every earlier decision is being viewed.

None of this means that physicians should turn every progress note into a legal memorandum. Healthcare providers already spend an enormous amount of time documenting, and adding pages of defensive boilerplate is unlikely to improve either patient care or legal protection. More documentation is not necessarily better documentation. What matters is whether the record captures the information that was important to the provider’s decision-making. If a patient’s presentation raises a genuine question about whether telemedicine remains appropriate, the chart should reflect how that issue was addressed. Material changes in symptoms, recommendations for in-person evaluation or a higher level of care, limitations created by unavailable records, and clinically significant coordination with other treating providers are the kinds of facts that may later matter.

Healthcare providers also tend to think about medical records primarily in connection with reimbursement. Does the documentation support the code? What happens if the insurer audits the claim? Those are obviously important considerations, but a medical record does not become legally significant only because an insurance company paid for the encounter. A patient may pay entirely in cash and the same chart can later become evidence in a malpractice case, professional licensing investigation, administrative proceeding, criminal matter or other litigation. The Clancy trial is an unusually dramatic example of that reality, but the underlying principle applies to everyday healthcare practice.

For telehealth practices, this is also a reason to look beyond individual charts and periodically review the systems surrounding remote care. Telemedicine protocols should provide clinicians with practical guidance about circumstances that may warrant escalation or an in-person evaluation. Consent forms should accurately reflect how the practice actually operates. Procedures for referrals, emergencies and coordination with outside providers should work in practice rather than simply exist in a policy manual. Most importantly, those systems should support clinical judgment rather than create another layer of administrative burden for physicians.

The appropriate response to the issues highlighted by the Clancy trial is not to make psychiatrists afraid of telemedicine or to expect clinicians to document every thought they have during an encounter. Physicians cannot practice medicine with knowledge of what will happen tomorrow, and compliance programs should not be built on the fiction that they can. What practices can do is create sensible safeguards around telemedicine and documentation so that, if a clinical decision is questioned years later, the record fairly reflects the information available to the provider and the circumstances in which the decision was made.

The Clancy case is extraordinary. The possibility that a medical record will someday be read by someone other than the treating clinician is not. A well-documented chart cannot predict or prevent every adverse outcome, but it can preserve something that becomes very difficult to recreate years later: what the provider knew at the time, what the provider observed, and why the provider made the clinical decision that was made.

At MDRXLAW, we work with healthcare providers and practices to review telemedicine protocols, documentation practices and compliance procedures before they become an issue in an audit, investigation or litigation. The objective is not to create more paperwork for physicians. It is to make sure that the systems surrounding them both support good clinical care and protect the practitioners who provide it.