Documentation best defense in a malpractice action

In the Courts. By Tanya Albert, AMNews staff. July 12, 2004.

Physicians hear over and over again that the best way to protect themselves if they are sued -- other than practicing good medicine -- is to "document, document, document." But what exactly constitutes good documentation? Here, litigator John H. Burtch, an attorney with Baker & Hostetler's Columbus, Ohio, office, tackled the issue for AMNews.

Question: Let's start with the basics: Generally speaking, how much detail should physicians include in their written records of what takes place during a patient encounter? What should never be omitted from the record? Is there ever a point where there is too much detail?

Answer: I have never been involved in a case in which the physician has recorded too much information. My rule of thumb is "the more the better."

While I don't totally subscribe to the proposition that "if it's not charted, it didn't happen," there is some truth to this adage in presenting a case in an adversarial proceeding before a jury. If the information does not appear in the chart, plaintiff's counsel always challenges the credibility and recollection of the physician.

With respect to omissions from the chart, it is my experience that physicians are particularly bad at timing their orders and entries. If there is one piece of information that is most helpful in defending medical malpractice cases, it is the time that the events recorded in the entry were performed.

For example, when did the physician make rounds and record his or her findings? When did the physician order a particular procedure or medication? Also, if the physician follows up subsequently to determine if the procedure has been performed or the medication administered, it is helpful for the physician to document his follow-up. Otherwise, plaintiff's counsel will make the claim that the physician did not follow through to see if his or her orders were followed.