It's Unprofessional to Point Fingers in Patient Notes

September 9, 2013
Melissa Young, MD

The hospital chart is a method of documenting care and a means of communication between providers … not a weapon against another provider.

The hospital chart is meant to be both a method of documenting what occurs during a patient’s hospital admission as well as a means of communication between the different healthcare providers - doctors, nurses, physical therapists, pharmacists, etc. It is not supposed to be a weapon against another provider.

Does that sound melodramatic? Am I perhaps being too sensitive? Paranoid? Maybe, but hear me out.

There is a patient that I had been seeing as an outpatient for her diabetes. In the last year, she has been in and out of several hospitals for surgery and surgical complications. She has also been in and out of rehab in between those hospitalizations. She has been seen in consultation by both myself and my associate to manage her diabetes when she is admitted to our local hospital, but we do not have privileges at the other hospitals to which she was admitted nor do we see patients when they are in subacute rehab. During her admissions and transfers, her diabetes medications have been adjusted by whichever doctors are seeing her at the time. The last time we had seen her was three weeks before this ER visit. At that time, she had been on a lot of IV dextrose and was on insulin.

Well, she was back at our ER recently because of hypoglycemia. I discovered she had another episode of hypoglycemia shortly after her last admission after the IV dextrose was stopped, she was brought to a different hospital, and somewhere in between oral diabetes agents were added.

Where am I going with this? Well, when she showed up at our ER this time, her surgeon wrote in his note "She… has been plagued with multiple issues including falls related to hypoglycemia which led to oral hypoglycemic agents directed by Dr. Melissa Young."

Really? Pointing fingers? Needless to say, I was angry; angry that he chose to name me, and essentially blame me for her ER visit. I would have been almost as upset that he would decide to name names if it were true, but since it wasn’t … well, let’s just say the computer I was reading his note on got an earful. OK, maybe there was no malicious intent, but then it was very careless of him to put me at risk of a lawsuit. And perhaps I should have prefaced this with a little history - he and I have had, let’s say, an animated discussion before about another patient.

My associate asked me if I talked to him. I didn’t. Maybe I should. This might keep him from doing it again. But I have this bad feeling that any discussion will not end well. Is it worth going to the department chief? I don’t know. Maybe I should just make a general statement to the chief about reminding physicians about how and what they document in the chart.

In today’s healthcare system and in the litigious society in which we live, it is very important that we document things accurately. I am all for admitting when a mistake is made, but placing blame in black and white can be disastrous for the accused regardless if the accusation is true.