Avoid these common errors in self-defense!

Notes enable defense attorneys to assert, with confidence, that, on a given date, patient and physician had a conversation or reviewed a handout, or that the nurse showed the patient a videotape. A record of this activity in writing makes it harder for the patient to claim, “The surgeon didn’t tell me any of these things.” The documentation can be as simple as a note stating: “Am CA Soc pamphlet reviewed with patient & husband; gave breast cancer booklet; nurse ran lumpectomy video.”

Keep postop notes specific

We’ve often found postoperative progress notes to be thin on detail. Typical notes are: “Wound looks good.” “Patient happy with results.” “Wound WNL” [within normal limits].

I recommend that you be specific in these notes. Describe the presence or absence of, for example, swelling, redness, adhesions, hematoma, drainage, fever, and regular urinary or bowel patterns.

When a patient claims negligent postop management, we often find sparse notes—sometimes a few words in the hospital chart or on the follow-up record. Nursing staff may identify fever, pus in the wound, and elevated laboratory values—yet the physician notes “Doing well.”

Without complete notes indicating the surgeon’s awareness of the patient’s condition, it’s impossible to convince a judge or jury that the surgeon was on top of the situation. Having inadequate notes makes the defense attorney’s job difficult.

Make the call, then write the note

Another gaping hole in documentation is poor notation of postoperative or posttreatment telephone calls during which a patient reports a significant change in her condition. Your policy may be “We never document telephone calls; we tell the patient to come in for a follow-up visit,” but what if the patient doesn’t show for the follow-up? There’s no evidence that an appointment was scheduled or that the patient failed to cancel or reschedule.

We’ve also seen situations in which the patient calls to report a problem and the medical assistant gives medical advice on the surgeon’s behalf because she (or he) has worked for the physician for, say, 15 years and “knows exactly what the surgeon would say.” We have seen that advice backfire because the assistant did not tell the surgeon what the patient said or because the staff member failed to ask how to respond to the patient’s concern.

And here’s another common scenario: The patient talks to the surgeon, who gives verbal advice but doesn’t document the discussion.

These are all dangerous areas in the use of the telephone. We advise physicians that telephone communication, including conversations after hours or when the physician is on call, must be documented. You simply cannot, ever, afford a gap in your documentation. (see “Telephone calls to and from patients: A right way to keep records,” and “Save those e-mail messages!”)