Accurate, thorough documentation is key in avoiding malpractice suits

September 29, 2006

When Edward G. Zurad, MD, offers advice for avoiding malpractice litigation, you'd better listen. He's speaking from experience.

When Edward G. Zurad, MD, offers advice for avoiding malpractice litigation, you'd better listen. He's speaking from experience.

Dr Zurad, from Temple University in Philadelphia, won the lawsuit filed against him, but not without hundreds of hours of lost time. To avoid another tedious trip to the courthouse, he developed a list of the top 10 ways to prevent malpractice litigation., and he hasn't been sued since.

  • Tell the truth, the whole truth, and nothing but the truth: Avoid subjective comments, complete all insurance forms, and document any lack of diagnostic uncertainty.

  • Write well and write often:Your notes should be legible, thorough, and accurate. Don't write data in the margins. Noting patient quotations can be helpful if you're ever sued.

  • See your patient before making the diagnosis: If possible, don't order medication without examining the patient, or at the very least make sure you review the patient's medical history before issuing prescriptions.

  • Pay attention to the little things: Watch nonverbal cues, be courteous, and reassuring.

  • Never underestimate vital signs: Always record and review temperature, BP, weight, height, and pain analog scales.

  • Communicate as if your job depends on it: Tell the patient what to expect during an exam, prolong office visits, use appropriate humor, and make sure patients understand their options.

  • Be nice, be yourself: Nice doctors get sued less often.

  • Know that others will read your charts: Don't even think about recreating charts with different information.

  • Consider all diagnoses, not just the common ones: Listen to the patient carefully, and revisit unresolved problems.

  • Stay alert, and don't forget the unusual: Don't rush, and remember "red flags."

Dr Zurad also urged the audience to adopt 7 strategies for helping patients understand risks, among them using visual aids, remembering that patient's emotions will determine their judgments, and providing a positive perspective. These foster a good relationship with patients and make them less likely to contemplate legal action..

It's ok to "fire" patients with whom you can't agree after multiple efforts, Dr Zurad said. Make sure to choose your words carefully, put it in writing, and, if possible, dismiss them in person.