Posts Tagged ‘malpractice’

OK… this is a shameless plug for one of the RookieDoctor.com products now made available. If you don’t like the fact that I’m going to promote something, then don’t watch this short video. I discuss the importance of your notes and documentation – from the clinical years of medical school on through internship and residency.

If you want to know how your progress notes, your H-and-Ps, your discharge summaries, etc can impact your evaluations, your future job offers, your letters for fellowship, the likelihood you will be sued, and more importantly, your patients’ lives, then check this out. It’s short, but it’s not sweet:

Developing good documentation skills can be a tremendous part of your training – with profound implications for your patients, the effectiveness of consults you request, your evaluations from attendings, and developing efficiency for your future work. I have been called several times, thanking me for my documentation – by malpractice lawyers, by risk management personnel, and once by the Chief of Medicine at another hospital – you would be surprised at the information that others find useful in your old notes.

Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.

1. Know who reads your notes – you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.

2. Write legibly – If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.

3. Use bulleted lists – Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.

4. Indent consistently – when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.

5. Consistent order of things – from note-to-note, stay consistent.

6. Refer to other parts of the documentation – It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13″ or “Exam is unchanged from 12/12″ or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.

7. Ask for specific feedback – ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”

Be very careful… Jokes and things done to make people feel better are not always about the intentions behind them. Even intending good, you may offend someone or make them feel violated. In this case, a surgeon was sued for giving a temporary tattoo. Kind of cute to some… deeply violated to others.

And the point is not to be careful just because you will get sued. No. Be careful, because you may leave someone feeling violated and you might get sued. Both.

Personally, I’d have trouble sleeping in either case.

Have you ever thought about who looks at your charting? Too often, what is written in the chart is thought of in real time only. When we write down our history, our exam, lab values, etc we’re thinking about providing good care to the patient right now. We may, at times, realize that a little later down the road a consultant might need what we’ve written, or something, but rarely are we thinking much further down the road.

You need to change that, and do it now. If you think about the full context of what you’re writing now – in your training – you will form good habits that will stay with you throughout your career. Check this out…

I once received a note I had written 4 years prior (from when I was a resident). It was faxed to me for my review. It turns out that another hospital was being sued by a patient they transferred to my hospital on a night I was on-call. I wasn’t being sued, but they needed my deposition, since I was the first doc to see the patient after transfer was initiated. And even though I wasn’t being sued, I felt nauseated seeing a note I had written years ago come across the fax… from Dewey Soo Em and Howe.

Here’s an incomplete list of (potential) eyeballs on your hospital charting. Please add more in the comments if you think of others…

• Attending physician
• Covering attending physicians – usually on weekends
• Nurse – usually a new one every 12 hours
• Consultants
• Pharmacists
• Pharmacy techs
• Unit secretaries
• Interns and residents
• On-call coverage, moonlighters, etc
• Coding department
• Billing department
• Utilization review personnel
• Social workers and case managers
• Insurance company reps and reviewers
• Other hospitals’ staff/docs (on future hospitalizations)
• Lawyers
• Patients, themselves (Google and Microsoft are both have patient-directed health care records)
• ChartFarts.com (medical charting funnies – whatever you do, don’t end up here)

Be careful with what you write or enter into the computer.