I had the recent pleasure of being a guest speaker for a seminar entitled “Confidentiality of Medical Records”. The written materials of this conference should be obtained by members of the medical community since they deal with issues of basic rules of documentation, common general legal problems, principals related to medical record documentation, confidentiality of substance abuse records and the appropriate way to obtain medical records. Some actual examples of medical records utilized in this conference are as follows:

1. “Patient experiences difficulty swallowing, tires easily.”
2. “History: Patient was shot in head with 32 caliber rifle. Chief complaint: Headache.”
3. “History: Patient has been married twice, but denies any other serious illnesses.”
4. “Prescription Rx: Vmycostatin – vaginal suppositories times 24, sig: insert daily until exhausted.”

These are humorous, although absurd examples of violations of the basic rules of documentation. It is recommended that from time to time every physician must consider the reasons for documenting patient care and, further, to determine “when” and “what” to document. These reasons include: a planning tool to promote continuity of care, document the course of illness/treatment, reliable means of communication for the health care team, basis for review of quality of care, establish a data base for education/research, provide a basis for payment, and to protect the legal rights of all involved.

Unfortunately, some physicians forget that one of the reasons for documentation is to protect their legal rights.

The basic rules of documentation from a legal perspective would include: document all findings which are essential to a diagnosis or patient care, document all findings (positive or negative) which are customarily documented in similar situations, records should be consistent (for example: laboratory tests, chest x-rays should be consistent with the clinical progress note), continuous processes which are unchanged need not be documented but should be, the description of a physical examination should clearly identify what was examined and the findings, document the possible diagnosis/complication/impression that are being considered and label the conclusion as a diagnosis complication or impression. All boxes, blanks or checklists on a medical record form should be completed (many physicians receive medical form checklists from drug representatives that are not entirely filled out for the medical records form of a hospital may have a box that was improperly checked, a specific example being a consultation sheet in terms of the timing of the consult and as to what management is to be provided).

Defending medical malpractice actions the records credibility and thoroughness as a professional accurate document is extremely important to the success of the defense. Many cases have been settled due to the lack of or inappropriate documentation. Some consideration as to professional accurate documents include avoiding expressions which imply disapproval or negative value judgments of the patient, avoiding expressions which imply the patient’s complaints are not being heard or taken seriously, you should describe assumptions made about the patient’s motives as possibilities rather than as statements of fact, and do not document your frustration with or disapproval of difficult patients. There are a number of things which should not be documented in the medical record, including professional debates, incident reports, staffing shortages, disagreements, reports relating to other individuals, and policies and procedures of the hospital.

The consistent structure of progress notes and good organization of the records’ contents will aid in more complete documentation of the care provided and can also assist an easy retrieval of vital information and prevent errors in patient care. The SOAP format (S = subjective data; O = subjective data; A = assessment and P = plan) certainly organizes unnecessary information but may not address unusual circumstances.

In the medical malpractice arena, there is no doubt that unusual circumstances or problems with patient care develop. These unusual circumstances that impact the continuity of care should be documented in a carefully prudent manner. It is suggested that these guidelines for unusual circumstances may be helpful:

Always document medical complications, mishaps, or unusual occurrences in the medical record.

Use terms that reasonably reflect what happened. Do not misrepresent the facts.

Omit all risk management/risk prevention activity from the record.

Legal threats and complaints about care may be briefly documented in a non-judgmental neutral manner, do not hesitate to seek legal advice prior to “committing testimony to print”.

A frequent occurrence is the non-compliant patient, however, the lack of documentation to reflect the patient=s responsibility undoubtedly, this is a common component to adverse health outcome, which many times develop into law suits. It is therefore imperative to document the patient=s responsibility which caused or contributed to the adverse outcome. This can be a helpful defense strategy. Patient non-compliance can occur due to a lack of education and even where the education has been provided, the patient will often claim they were not informed. Therefore, it is imperative the medical record reflect the information provided to the patient and to the patient’s family. Some issues to be concerned with in terms of documentation of non-compliance is to document the worries or concerns expressed by the patient or the family member, document sources of information if other than the patient, document information given to the patient at the time of discharge, document pertinent information communicated via the telephone (and save your phone messages).

From time to time it is best to be reminded about the significance of the medical record. In many malpractice cases the record carries much greater weight in defending a case than the doctor’s actual testimony. If prepared adequately and contemporaneously with patient care it can be one of the best defense tools available in malpractice actions.

Submitted by:

CLINE, CLINE & GRIFFIN

José T. Brown

This entry was posted on Saturday, February 21st, 2009 at 12:59 pm and is filed under Medical. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.