A paralyzed patient with two stories in the chart

Hospitalist note, day 2: "There is less pain, actually no pain. The numbness or lack of sensation is improved. The ability to move his left leg is also improved; however, it is still difficult to move it and not because of pain."

Discharge summary: "There were no unifying localizing findings to suggest spinal cord compromise, and much of his symptoms may be related to pain. ... there has been no real progress made in terms of controlling his pain."

Taking all the evidence in aggregate, the plaintiff experts were critical that Dr. Hospitalist seemed unaware of the full range of patient symptoms, the laboratory evidence for an inflammatory process, the reliance on a specialist who never examined the patient, and the inadvertent or intentional chart contradictions.

Conclusion

Charting is one of the four "Cs" in reducing medicolegal risk (charting, competence, compassion, and communication). In this case, the charting by Dr. Hospitalist appeared appropriate on the surface, but inadvertently or intentionally hid the entire clinical picture. The difference in documentation between hospitalist and the RN/therapy notes in this case seems hard to explain, but various health care providers may reasonably see and chart diverse findings and impressions. However, the conflicting documentation between several of Dr. Hospitalist’s own notes severely damaged his credibility.

This case was settled for an undisclosed amount in favor of the plaintiff.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read earlier columns online at ehospitalistnews.com/Lessons.