Document, document and document some more.
Over the last 25 years, I’ve seen more than 50 lawsuits come across my desk.
Before you draw the conclusion that I’m either a terrible physician or have litigious patients, let me explain.
Early in my career, I was given the opportunity to sit with a malpractice lawyer, who taught me the best practices for preventing lawsuits. He would hand me a chart, ask me what was right or wrong with it and if I saw any medical malpractice involved. I reviewed chart after chart, looking for subtle items that either supported the documentation, or those items that were lacking or would cause a conflict with what a physician noted.
I currently serve as a medical expert. Throughout my career, I’ve applied the knowledge I’ve gained reviewing medical records for medical malpractice lawsuits. I have reviewed cases for both the plaintiff and the defense. I continue to learn from each case I review.
Some of the lessons that I pass onto students-and to fellow physicians-from the cases I’ve reviewed, include:
Document, document and document some more. If it isn’t documented, it wasn’t done and there is no going back once that note is closed. So dot your “i”s and cross your “t”s before you move on to another note. For those using paper records, make sure all entries are legible. For those using electronic health records (EHRs)-and even those who aren’t- make sure your documentation is complete and accurate.
In your EHR, do not clone notes (i.e. “copy and paste”). It will get you into trouble every time.
Review medications, even if your nurse or medical assistant reviews them. I find more mistakes in the medication section than anywhere else in the medical record. Review medications for drug interactions, which becomes much easier with an EHR.
Look closely at the adverse effects of medications and do not treat the side effects of one medication with another medication, as this could lead to more complications and adverse events.
Follow up on tests. I set an alarm for an order. If after a week I don’t see that the test is done, I start to make phone calls looking for test results or if the patient actually had the test done.
But most of all, be humble. If you are wrong, apologize to the patient and be sure it is clear what you are apologizing for.
Be compassionate. There is a big difference between being sorry out of sympathy for spotting something negative in a test and apologizing because you made an error.
Don’t be arrogant. Arrogance and a poor attitude and will get you in trouble.
And never forget that subtle symptoms warrant investigation. Investigate, investigate and investigate some more. If a patient has a persistent symptom, check all the possible causes and don’t give up. Some may accuse you of over-testing, but there has to be a reason for the symptom. If at first you don’t see something, try something else to get to the bottom of the issue plaguing your patient. Not only will this prevent litigation, it’s what patients expect of us.
Follow my advice and you can avoid seeing a lawsuit on your desk.
George G. Ellis, Jr, MD, is an internist practicing in Youngstown, Ohio, and the chief medical adviser for Medical Economics.