A Medical Economics Web Exclusive

Overdocumenting can get you sued

Doctors often don't document enough. But writing too much in our charts can cause a heap of trouble, too.

By John Egerton, MD
Family Practitioner/Friendswood, TX

By now, it's been well drummed into our heads: In the malpractice arena, if you didn't write it, you didn't do it. But it's possible to be too diligent at keeping defensive records. In my opinion, we sometimes include too much, and those entries can come back to haunt us.

Here are some examples.

Setting a new standard of care

An orthopedic surgeon provides meticulous reports on consultations I send him. Lately, his reports mention that he's warned patients of the importance of doing routine lab tests after being on NSAIDs for two months to check for deterioration in liver or kidney function.

Now, as far as I know, no lab tests are mandated when prescribing NSAIDs. Recommending the tests may be very conscientious medicine, but there are a couple of flaws. First, no baseline lab was done before prescribing; and second, it's not clear who should do the lab after two months—the orthopedist or me. So for that rare patient who will develop a problem, who is responsible? Having set the rules, and put them in writing, the orthopedist has set a standard of care, not only for himself, but for me, too.

By being defensive, this specialist may have opened another door to a plaintiff's lawyer.

"You knew the dangers of these drugs, Doctor, yet you didn't do the recommended test that would have warned you that my client was about to suffer these terrible consequences."

Venturing into areas beyond our training

An ENT specialist I used to refer to made a habit of advising me in areas outside his specialty. I would send a patient to him for his opinion; then I would get a letter back saying, for instance, "Mr. Bloggs complains of nocturia, and I have recommended that he be referred to a urologist."

Now, I knew Joe Bloggs drank a six-pack of beer before retiring each night and had had nocturia for years.

"Didn't you tell the specialist this?" I asked Mr. Bloggs.

"I told him I was a social drinker," he said shyly.

But now the seed was sown in the form of a specific recommendation recorded in a specialist's letter. If I don't follow it, and something unexpected showed up later—trouble! So now I have to decide whether I should send Mr. Bloggs for what will almost certainly be an unnecessary consultation. If I don't, I risk a future interrogation like this one: "Let me get this straight, Doctor. The specialist you sent Mr. Bloggs to put down in writing that my client needed to see a urologist, yet you ignored this doctor's advice. Is that correct?"

Flagging follow-ups, then ignoring them

I once made a note in a patient's chart that I should do a chest X-ray as follow-up in three months. I even underlined the note to emphasize its importance. Then I went on vacation, the chart got filed, and I forgot all about it.

Fortunately, the patient called for something else a month or so later. That jogged my memory, and we got the X-ray done. It was normal. But how easy it would have been for him to have slipped through the net, and how difficult it would have been for me to answer the question, "Doctor, why didn't you do the X-ray that you thought was so important and might have prevented this terrible thing happening to my client?"

The other day, I saw an overweight, hypertensive patient, and noted that I had recorded, almost a year earlier, that I needed to address the matter of diet and exercise. But a few weeks after I wrote that note, the patient had an acute problem with something else, and so, many months later, there was no official record of my doing what I had recommended.

On minute examination of the chart, such an omission can make one's practice seem sloppy and incomplete. "You obviously thought that my client needed advice on her lifestyle, yet you didn't follow through. Do you think, Doctor, that she would have had this terrible heart attack/stroke/thrombosis if you had done what you said you should do?"

Jotting down every incidental symptom

I had written, "Patient complains of abdominal pain," as an incidental symptom during a routine examination. I remembered that this was associated with an acute gastroenteritis and that I had merely made a note for my own memory. But that's not how a lawyer would see it.

"Why did the patient have abdominal pain, Doctor?"

"I think she had acute gastroenteritis."

"You don't think it might have been due to this chronic condition you failed to diagnose?"

"No."

"But you didn't say so at the time."

If it's important enough to mention at all, then do it completely.

John Egerton. Overdocumenting can get you sued.

Medical Economics

May 23, 2003;80.