Optimize Your Documentation

In virtually every medical malpractice lawsuit, one factor stands out as the single most important weapon in the defense of the accused physician: the physician's documentation. In this blog post, I'll explain why documentation is so overwhelmingly important, and I'll provide some tips on how to improve your documentation.

1. Your document will probably be the only physical record of the event. 

Cameras seem to be everywhere now, but they're rarely found in operating rooms because of patient privacy concerns. Therefore, your documentation is often the only piece of physical evidence that will remain from an event. Unlike peoples' memories, it will never fade. It will be copied countless times, scrutinized, magnified, and analyzed--every comma, word, and letter. 

2. The expert witness uses your documentation to form their opinion about the quality of your patient care.

Your expert witness' opinion about your delivery of care will depend heavily, perhaps even exclusively, on your documentation. Two reasons here: 1. In most cases, the expert witness and the defendant never communicate with each other. Why not? That communication isn't protected by attorney-client privilege, and therefore, anything the two of you discuss is actually open to discovery. Bottom line: you won't be able to "fill in the details" or "explain yourself" to your expert witness. 2. The expert witness can also give their opinion about your care based on the depositions of other witnesses, but in the majority of cases, the other people getting deposed are not anesthesia providers, so their input isn't likely to help you much.

3. In most cases, a lot of time has passed between the event and the deposition and/or trial.

It's amazing how much people "can't recall" when sitting in a deposition chair, especially when a couple of years have passed. 

4. Trust no one--Everyone is in CYA mode when they get involved in a lawsuit.

If you remember nothing else from this blog post, or heck, this entire blog, do me a favor and remember this one detail: everyone, and I mean everyone, will be in "cover my a**" mode when they're involved in a lawsuit. No one, absolutely no one, will come to your defense. Your documentation will be your only friend--but only if you do it right.

So, here are a couple tips to make sure your documentation is optimized.

1. Practice what I call "mindful documentation". What's that? It means: do something more than simply checking boxes. Write something specific that clearly shows you personally spoke with the patient and  reviewed the medical record. For example, when noting the pt's exercise tolerance, I often write exactly what exercise they do, i.e. golfing, walking. In addition, I often take a couple of extra seconds to manually type out the pertinent aspects of the patient's medical history, such as: "PMH main points: EF 30%, A-fib, off Xarelto x5 days, denies recent illness, poor functional capacity". Anyone who reviews my documentation will think, "hey, this guy really took the time to read the chart and make note of the pertinent issues." 

2. Meticulous, detailed oriented documentation = meticulous, detail-oriented clinician. With few exceptions, your document is the one and only work product that can be examined from the episode of care in question. Reviewers will look at your documentation and, rightly or wrongly, form a judgment about what kind of clinician you are. If your documentation is slop, it's not a stretch to think that your clinical care is also slop. But if your documentation is detailed and precise, it's reasonable to think that your clinical care is detailed and precise. You see where I'm going with this. Your documentation really sets the stage for your defense.

That's it for today!