A Medical Economics Web Exclusive

My incomplete charting nearly did me in

Sued because his documentation didn’t reflect the treatment he’d provided, the author was rescued by a surprise source.

By Henry Friedensohn, MD
Family Physician/Lauderhill, FL

It’s often said that physicians who develop good rapport with patients don’t get sued. I thought I could bank on it. Boy, was I wrong. My first and only lawsuit taught me that the only real protection in a malpractice case is solid documentation that shows you followed the standard of care.

I’d retired to Florida in 1987, but after a while I took a job with a senior clinic to stay busy. And stay busy I did. My two colleagues and I were limited to 15 minutes per patient office visit, and walk-in emergencies had to be squeezed in between scheduled appointments.

It felt like a MASH outfit in Korea: constant overwhelming stress, the daily onslaught of disease, and not enough time to practice quality medicine.

Still, we did our best. After 25 years of practice, I knew how to spread myself over 25 to 30 patients per day. I could cut corners without compromising my ability to pick up the major presenting pathology and refer patients to the appropriate specialists. Fortunately, our administrator facilitated our referral requests and helped us provide a decent level of care.

But the pace made it hard to write and maintain adequate charts–a problem some of my colleagues solved by spending three to five minutes on diagnosis and therapy, and the remaining 10 minutes on their charts.

These doctors’ chart reviews were always beautiful; mine were lousy. I was told my handwriting was illegible and that my documentation and detailing were poor. But I refused to change my working habits. I felt strongly that I should spend my limited time on patient care.

I assumed that this approach would allow me to build rapport with patients, which would protect me against malpractice complaints. There didn’t seem much likelihood of one anyway, since no physician in the center had ever been sued. Still, I knew the risk I was taking. I pleaded for dictation charting, but was told it would cost too much.

Five years into the job, the bomb hit. My administrator handed me notice of the impending suit. In Florida, the letter of intent to sue–called a "pre-suit affidavit"–is written by a physician. The internist who wrote the letter charged that my "negligent care" had caused my patient suffering and precipitated an otherwise unnecessary operation.

The patient I’ll call Rose was a 70-year-old woman with a 20 year history of chronic recurrent duodenal ulcers. She had eventually developed pyloric stenosis requiring a partial gastrectomy. The internist’s letter claimed that this procedure could have been avoided if only I had treated her with appropriate dosages of H₂ blockers during acute flare-ups, and prophylactic dosages during quiescent phases.

I studied Rose’s chart closely. I had cared for her for the prior five years. She would show up periodically because of exacerbation of duodenal ulcers. I treated her with recommended dosages for acute flare-ups, and in between with antacids and other prophylactic medicine at recommended dosages.

I looked to make sure I had documented the dosages and frequency of script renewals, but my negligent charting did me in. Although I knew I had followed the standard of care at the time, my chart did not corroborate my actions. Certainly, the plaintiff’s lawyer had noted this.

It bothered me that my charting didn’t reflect my excellent care, but I was just as upset thinking about Rose. She was a lovely lady with whom I had always had good rapport. It stung that she valued a potential pot of gold more than our relationship.

I wrote a long statement explaining that a pyloric stenosis was inevitable–the result of scarring of the duodenum by recurrent ulceration. Not surprisingly, their experts disagreed.

I was assigned a very competent lawyer by my insurance company, and we spent hours reviewing the case. The insurance company agreed with me that we shouldn’t settle, even though my poor chart notes weakened our case. I was sure I had treated her correctly and confident that the truth would prevail.

At one point it occurred to me that someone must have a record of the numerous prescriptions I’d written for Rose. So I walked through the surrounding area, asking pharmacists whether they’d filled any of my scripts for her.

One pharmacist recalled Rose’s name. I asked him to search the computer for as many of my scripts as it held in its memory. When I returned the next day, he had every script for the past five years. I was astounded. (God bless the inventor of computers!) There, in black and white, was absolute proof of appropriate dosage and frequency.

At mandatory arbitration, the plaintiff’s counsel had the opportunity to depose me. The questioning began slowly but then intensified. He must have asked me at least 100 questions concerning my credentials.

The one question he didn’t ask: "Doctor, you have presented yourself as a board certified family physician. Please tell me where you did your residency."

Obviously, he was saving this question so he could make me appear to be a liar in front of the jury. He knew I hadn’t completed a residency.

What he didn’t know was that my situation was perfectly acceptable to the American Board of Family Practice. After 1978, physicians had to complete a residency before sitting for the family practice boards. But doctors like myself had been grandfathered in, and I’d kept up my board certification. However, I didn’t volunteer this information, confident that I would be able to foil his ploy at trial.

The plaintiff’s lawyer then questioned every detail of Rose’s chart, intending to spotlight its deficiencies. Throughout, Rose, who sat at the other end of the table, never looked me in the eye.

We ended the day’s questioning without reaching any compromise. Just before I left, my lawyer advised me that the best way to head off a lengthy and expensive trial was to show the other side the pharmacy report. When I handed it to the plaintiff’s lawyer, he played it quite cool. But by the time he’d finished reading it, the color of his skin looked a few shades lighter.

Although a court date was set, I wasn’t surprised to get a phone call from my attorney several days beforehand. "Guess what?" he said. "They just withdrew the case."

What did I learn from all of this? First, trust no one. The million-dollar awards made by ignorant juries are so common that no matter how good your rapport is with patients, they’ll always be tempted to sue if given the opportunity.

Second, never put yourself in a position where there’s no time to document your charts correctly. While you’re charting, keep in mind that every word may some day be read to a jury. Don’t give plaintiffs’ attorneys any ammunition.

Henry Friedensohn. My incomplete charting nearly did me in.

Medical Economics

2001;11.