“Phrases like ‘hysterical’ or ‘oversensitive,’ ” he says. “Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.”
O’Rourke also says while most physicians are good at documenting what they did or saw, they don’t usually do a lot to explain why. “Making clear your thought process is good in court, in part because doctors often don’t remember a lot years later in front of a jury.”
Documentation should reflect the process of differential diagnosis, O’Rourke says. “If a patient is having difficulty breathing, for example, it could be pneumonia, reactive airway disease, allergies, or a cold. The record should explain the basis for the doctor’s diagnosis and treatment actions.”
Never go back and change records—that undermines their credibility with juries, O’Rourke advises. “You have to make corrections with an addendum, the date and time, and reason for the change,” he says. “Since records go to insurers and other providers, they have to match. In court, the doctor really loses credibility when they don’t.”
It’s also risky to overuse medical abbreviations, says O’Rourke. “A recent study found that 5% of 30,000 medical errors were due to medical abbreviations.” He notes that the Institute for Safe Medication Practices has a list of error-prone abbreviations, symbols, and dose designations on its Web site (www.ismp.org/Tools/errorproneabbreviations.pdf).
Legibility
Another big problem with documentation is legibility, says O’Rourke, noting that many lawsuits have arisen from wrong medications and dosages. “Illegibility causes many medical errors that are preventable,” he says.
“Physicians must remember that just because they can read their writing doesn’t mean others can,” says O’Rourke. “Doctors think the records are their records, but they’re really the patients’ records. If other doctors, pharmacists, etc., can’t read them, why make them?”
Joseph Li, MD, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston, also says illegibility is a big problem. “Physician signatures must be legible,” he notes. “It’s critical to know who wrote the notes. If someone doesn’t know something or can’t read something, they can find out.”
Yet “just telling physicians to write legibly doesn’t work,” says Dr. Li, who is also an assistant professor at Harvard Medical School. “Doctors need to print their name beneath their signature.”
Dr. Li’s group uses templates for admission and progress notes. They include the names of each physician with a check box so they can indicate who wrote the notes. “This is how we comply with that guideline from the Joint Commission on Hospital Accreditation,” he says.
Robert Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, has reviewed malpractice cases for hospitals and lawyers and in his current role focuses on deficiencies in documentation. He has seen numerous kinds of inappropriate information in medical records. Among his suggestions:
—Patrick O’Rourke, an attorney for the University of Colorado, Denver
Don’t try to settle a dispute in a chart. Dr. Rohr recalls a patient who had a leaking abdominal hernia. A resident wrote in the chart the patient should have surgery within six hours or he would die. The surgeon disagreed. The patient lived without having surgery within the six hours, but if the case had been litigated, the chart note could have been used against the surgeon. “Settle things face to face or on the phone. The medical record must only detail your best thinking about the patient,” says Dr. Rohr. “Don’t be speculative. Agree on a course of action with other physicians and make documentation represent the agreed-upon plan. Showing differences of opinions helps plaintiffs’ lawyers.”