A. Clear, accurate, and complete documentation is necessary primarily to protect your patients. Careful documentation helps prevent errors and injuries by subsequent treating physicians who rely on your records. And, yes, good documentation also protects you if you're sued for malpractice.
Good charting need not be onerous, though. Your charts should contain enough information so that medical experts who examine them during litigation or physicians who consult them as part of a peer review can determine whether you met the standard of care. They should include sufficient detail to justify your decisions to provide, change, or delay treatment. They should cover the patient's complaints as well as your history and physical findings, diagnosis, medications, treatment, and your advice to the patient. They should also record any drug or food allergies, and the results of any tests and procedures.
Such unclear notes often lead to settlements and plaintiff's verdicts in cases in which the doctor provided appropriate treatment, but the documentation doesn't confirm that care. Juries are reluctant to accept a physician's recollections about undocumented treatment, and they give little credibility to chart entries made after an injured patient files a claim.
Take the case of a highly-regarded family physician who was sued for failing to diagnose breast cancer. His colleagues described him as a careful, meticulous practitioner. But after reviewing the doctor's sparse medical records in this case, none of them-and no expert-was willing to testify on his behalf. As a result, he was forced to settle.
If the patient hadn't developed breast cancer, this doctor's incomplete charting wouldn't have become an issue. But when an adverse outcome does occur, medical experts, attorneys, and jurors often rely on the patient's chart to determine whether the doctor's care was appropriate.
In another case, a mother came to a pediatrician's office with her son who had a small object embedded in his ear. After trying several times to remove it without success, the doctor referred the boy to an otolaryngologist, who managed to remove it. Months later, the woman sued the pediatrician, claiming he had perforated the child's ear drum.
In his defense, the doctor testified that the mother told him she'd tried several times to remove the object herself-with a Q-tip-before coming to his office. Unfortunately, he hadn't documented that detail, and the mother denied it. As a result, the jury didn't believe him, and found him negligent.
For all these reasons, the importance of careful documentation can't be stressed enough.
The author is a risk management and loss prevention consultant in Cloverdale, CA. He can be reached by e-mail at firstname.lastname@example.org
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