Documentation Tips to Avoid Malpractice Suits

More often than not, documentation will make or break a malpractice case. Too often these days, physicians seem to obsess over the relationship between documentation and E/M coding levels fearing a Medicare audit and potential financial penalties. But the threat of a chart being examined by a plaintiff attorney far overshadows the damage you might sustain from an audit. When charting patient visits, aim for consistency and thoroughness.

Here are some common-sense tips for reducing your risk of being sued - and improving your chances of successfully defending yourself when the (almost) inevitable finally does happen.

• Always record vital signs. Missing vitals can be ruinous, especially in “failure-to-diagnose” cases.

• Include a carefully documented history and physical — never miss an opportunity to incorporate the patient’s own statements regarding history and present illness.

• Write what’s important. Standardize your “standard operating procedures” so that even when a record may not note that you included a particular step, you can confidently show that you always include it in similar circumstances. The further an examination deviates from routine or normal, the more important it is for you to document that anomaly.

• Make sure notes are legible — enough said.

• Don’t be inflammatory, judgmental, or derogatory in your notes. Who might eventually read the record?

• Get informed consent. A signed document doesn’t provide enough protection in itself. Include a statement in your note that records that the procedure, risks, consequences, complications, and alternatives have been explained to the patient who understood and accepted the explanation.

• Document every test ordered or recommended as well as the results.

• Document noncompliance and your subsequent efforts to explain the risks of noncompliance. (Consider discharging chronically noncompliant patients.)

• Note insurance denials and your subsequent explanation to the patient including that you disagree with the decision and will support the patient if he or she wishes to appeal it.

• Never alter entries.

• Consider dictating your office note in the patient’s presence. It provides generous opportunities to answer patient questions and reduce misunderstanding.

• Document phone calls thoroughly.

Careful follow-up with your patients can be your most effective defense against being sued in the first place. And if you are sued anyway, it demonstrates your thoroughness. Follow-up should include:

• Close the loop on test results; create a system that pursues late or missing results.

• Notify every patient about test results — good and bad. And document all of it.

• Don’t settle for uncertainty. Always schedule a re-check in a week or two when you are tentative about a diagnosis. Refer the patient for testing and/or specialist examination.

• Make referrals happen — especially in high-risk cases. Use your office staff to call the specialist’s office and facilitate the appointment.

• Create a sensible schedule for follow-up visits for patients with chronic conditions.

• Manage medication changes actively.

• Review patient charts before each visit.

• Ensure effective communication with anyone covering for you when you are off-duty.

• Supervise non-physician providers carefully.

• Know your limitations; don’t attempt procedures for which you are minimally qualified.

• Don’t try to “force” a procedure on a noncooperative patient.

Finally, recognize that many malpractice suits don’t start in the exam room or hospital. Create a patient-centered, service-oriented office environment that maintains good patient relations:

• If you have to keep patients waiting, tell them what to expect. Have staff explain delays and give estimates for when the patients will be seen. Give first priority to patients who have to reschedule because your day fell apart.

• Give patients full attention when in the exam room or at the hospital bedside.

• Don’t interrupt.

• Pay special attention to the patient’s sense of privacy at every level.

• Treat patients as people, not as medical conditions.

• Always involve the patient in decision-making.

• Don’t criticize other treatment a patient has received.

• Ask patients what they think of your practice and how you might improve.

• Follow up with angry patients.

• Don’t tolerate staffers being inconsiderate to your patients.

• Be yourself — be a human in the presence of your patients. When appropriate, talk about your family and your personal interests. It’s much easier to sue a cold professional than a warm friend.