Don’t use charts as note pads for drawings, doodles, or other extraneous markings. “Nothing should be on the record that doesn’t help the next physician care for the patient,” says Dr. Rohr. “It makes the chart look unprofessional. Not good in court or anywhere else.”
Don’t leave the impression that you haven’t done a complete exam. Dr. Rohr saw the documentation that says a patient was “seen without chart.” Instead, he says, doctors should collect as much history as possible. “There are other ways to get information,” he asserts. “Doctors should shy away from making statements in charts about what isn’t available. Instead, outline all the information that is.”
Don’t just run through standard descriptions. Give a specific description of what you have actually examined and then state that “no other abnormalities were seen.” Errors and inappropriate information often go into records within standard exam information, Dr. Rohr and others say.
Avoid controversy in the chart—or, in Dr. Rohr’s words, “Don’t confess to malpractice.” “Don’t put things in charts that indicate you haven’t given the patient your best,” he says, recalling the physician whose chart mentioned a referral to a physician with uncertain credentials.
Be careful in documentation about whether a patient can afford a treatment. Payment issues should be worked out elsewhere. “You are in jeopardy if you give a patient less treatment because they can’t pay for it,” he warns. “It would look bad to a jury. You can include that a patient refused a treatment, but you don’t have to say why.”
Be as complete as possible, including all pertinent detail of a patient’s history. “You need to be thorough for the medical professionals who will treat the patient after you and you need to note certain conditions accurately for appropriate payments to physicians and facilities.” That need to create records that serve regulatory and billing purposes is becoming increasingly important to physicians and hospitals. TH
Karla Feuer is a journalist based in New York.