Physicians that practice smart documentation will be in a better situation to defend their actions if a malpractice lawsuit arises.
You practice great medicine, care about your patients, and strive to improve on a daily basis.
Still, despite your best efforts to provide the best patient care possible, many of you will face a malpractice lawsuit at some point in your careers.
According to a 2010 AMA report based on a survey of 5,825 physicians from the 2007-2008 Physician Practice Information (PPI) survey, the majority of doctors older than 55 have been sued at least once.
One way to ensure you are prepared if a malpractice lawsuit does head your way: practicing great documentation. Here are four smart documentation tactics that physicians should keep in mind:
1. Document your due diligence. As more practices implement EHRs, more malpractice claims are arising related to their use, Jeff Brunken, president and chairman of the board of The MGIS Companies, Inc., a physician insurance provider, recently told Physicians Practice. Make sure you document why you selected you EHR, and make it clear that you selected it because you believed it would enhance patient care, not because it was the cheapest system. Also, document any training staff and physicians received on the new system to demonstrate your due diligence, said Brunken.
2. Take your time. When using your EHR, it may be tempting to look for ways to cut down your time spent documenting. But be wary of shortcuts, cautions William McDonough, the 2013 president of the Massachusetts Society of Healthcare Risk Management. "We still find that physicians are getting in trouble because of an often-used process called cut and paste where they may cut and paste a history and physical that's over a year old, and quite frankly, that's no longer applicable," he recently told Physicians Practice.
3. Don't over-share. You need to document as thoroughly as possible, but always keep your documentation professional. Avoid improper, inappropriate, or rude comments, such as those related to a patient's appearance, Mike Atchison, an attorney at Burr & Forman LLP based in Birmingham, Ala., recently told Physicians Practice. Another key area to avoid in documentation: criticizing another physician for what he did or did not do related to the patient's care, said Atchison. "I've seen a good bit of that over the years, and it always comes back to haunt you."
4. Review the record. When you receive a request for release of a patient's medical record (from a patient or from another physician involved in the patient's care), don't rush to release the record immediately, cautions podiatric surgeon Tom Del Zotto. While patients have a right to their medical records, you need to thoroughly review the record before it is released. "There could be information that needs to be in the chart that hasn't been filed, there could be a dictation that has to be done before the chart leaves the office," said Del Zotto. "It could be something very small but it could be huge if it were to play a role in litigation."