The chart is your lifeboat
Documentation serves to prove you did the right thing and supports the idea that you’re a careful and caring physician who gave adequate thought and consideration to the case.
Juries tend to be forgiving of mistakes as long as the physician took the time to listen to the patient and family, took the time to collect the info and properly analyze it; they are equally intolerant of the sloppy and careless physician → Documentation can paint one of these two pictures.
Inaction explained → Document your thought process regarding why your work up is limited in scope.
-Use your Medical Decision Making (MDM) section of the note to explain why this patient does not have a Subarachnoid or meningitis and does not need CT Head or Lumbar Puncture.
Read the nursing notes and all other ancillary staff notes, medical student notes included → an MD Note does not trump an RN note.
Address abnormal vital signs.
There is no better way to completely discredit your chart then not documenting a complete physical exam related to the chief complaint.
-No neuro exam for headache, neck pain or back pain.
-No pelvic/ testicular exam for lower abdominal pain.
There are risks to writing the next great American novel in your differential diagnosis.
If you write "meningitis" in your differential diagnosis but don't start antibiotics and LP you should explain why.
The most important note is the last note --> All patients should have a reassess note conveying that this patient was safe for discharge.
Becareful with the "macro" or templated chart --> This can make you look sloppy and discredit your chart --> a discredited chart = a failed defense.
Acknowledge each complaint of the "poly positive review of system patient".
Never alter the record to make it appear as if edits were made at the time of the case.
"If you did not document it, you did not do it." --> this is a myth.
You are entitled to testify that you remember something you did even though you did not document it.
You are entitled to testify that you may not remember doing something but you are sure you did it because it is your custom and habit to do X when Y occurs.
-Example - Fecal occult and rectal exam for every rectal bleeding patient.
While it's important to optimize your documentation, spending too much time with the chart takes valuable time away from patient care.
THE NUMBER 1 RISK MANAGEMENT PEARL WILL ALWAYS BE: The best “defensive medicine” is good medicine.
Risk management is how do we minimize the chance of getting it wrong and not how do we avoid a lawsuit.
Weinstock, Michael B., et al. Bouncebacks!: Medical and Legal. Anadem Publishing, 2011.
Risk Management Monthly Podcast, Dr. Greg Henry, Dr. Rick Bukata, Dr. Mel Herbert.