Most physicians know the basic dos and don’ts of accurately documenting notes in a patient’s medical record. However, problems often arise when documenting a disagreement with the findings of another provider, or when using descriptive language about the patient. The wrong choice of words may be perceived as biased or disrespectful.
Despite physicians’ best efforts to correctly diagnose and properly treat patients, documentation snafus are bound to happen, and the fallout can be profound–whether having to defend yourself in court having to defend your reputation among patients and peers.
Here, we provide some practical tips on how to document with civility, sensitivity, and accuracy.
Documenting Disagreements
“The medical record is a method of documenting and a means of communicating amongst providers, not a weapon against another provider.”1
In an article entitled Avoiding Chart Wars, Keri Gardner, MD, MPH, FACEP, writes,2 “One of the most frequent calls I get from providers is about how to document disagreements. Disagreements are inevitable and always need to be handled delicately.” In the article, Dr. Gardner presents two cases that both demonstrate acceptable documentation to avoid potentially damaging finger-pointing:
Case 1:
A 50-year-old diabetic admitted to an emergency department has a painful cellulitis with a temperature of 101.3 and a heart rate of 105 after fluids. You think he needs admission, but the hospitalist disagrees.
The chart should reflect that you called the hospitalist for admission and the reasons why the patient needs admission. Avoid saying, “the patient looks too ill to go home” or similar. Simply state: “The patient looks ill and is tachycardic with decreasing blood pressures, admission requested for IV fluids and antibiotics, Dr. Hospitalist here evaluating patient.”
It becomes much trickier if you must discharge a patient that you believe needs admission. Restate the previous quote, but then conclude “Dr. Hospitalist has evaluated the patient and does not feel admission is warranted, please see his note for details. Patient is tolerating POs and has ability to return to the ED if needed and agrees with hospitalist’s discharge plan. Dr. H has asked me to discharge the patient home. I have asked the patient to return for reevaluation immediately if …” It is essential that you do not rant about how ill-advised it is for the hospitalist to send the patient home because you are obliged to advocate for the patient. If you strongly believe that the patient requires admission, you need to notify your departmental chief or chief medical officer (CMO) that this is an unsafe patient discharge. If you are not strongly enough against the discharge to call your CMO, then don’t hang yourself by saying that you totally disagree with the discharge. When you write the discharge order, you are going to be held responsible for it.
Case 2:
The consultant will not come in until certain tests are done—again, you are the only one on scene so you bear the brunt of the responsibility. If you feel the consult is emergent, you must tell the consultant so and move up the hierarchy if the consultant does not comply. If you feel the consult should come now, but you aren’t ready to call your departmental chief or CMO, then say, “Dr. Surgery was called to see patient, but would like a CT scan first. Informed that patient has an acute abdomen with a BP of 100/55 and HR of 115. Dr. Surgery would like antibiotics and CT prior to surgical evaluation.” Then keep a close eye on the patient and make any additional phone calls as they are needed if the patient condition changes.
Important “Don’ts” When Documenting
Crico, an organization that provides risk management and insurance coverage to all Harvard medical institutions and their affiliates, published a seminal article3 advising healthcare professionals to avoid the following documentation pitfalls for patient medical records (and we couldn’t agree more):
Derogatory or discriminatory remarks. In 2021, a federal rule went into effect granting patients the right to electronic access to all their health information without delay, upon request, and at no cost. It’s more important than ever to be mindful of language that may be viewed as disrespectful or prejudicial. Include socioeconomic information only if relevant to patient care.
Arguments/conflicts with other physicians, nursing staff, or administration. Address these issues through the appropriate chain of command, not through the patient's medical record.
Subjective statements regarding prior treatment or poor outcomes presented as facts. Use quotation marks to indicate patient’s or family’s impressions, e.g., “cerebral palsy due to a birth injury.”
After an adverse event. Do not write any finger-pointing or self-serving statements in the patient's medical record.
Non-patient care information. Do not include the filing of incident reports or referrals to legal services.
“READ” to Help You Write
Dr. Gardner also recommends using the easy-to-remember acronym, READ, to effectively document patient records:
Respect the patient in your documentation.
Eliminate hot-button words or words that
suggest bias.
Advocate for your patients by going up the hierarchy when you disagree with consultants; otherwise simply describe the disagreement factually and without emotion.
Document respectfully.
Dr. Gardner concludes, “Malpractice attorneys love using your own words against you. Don’t let them! A carefully documented medical record is a gift to your future self.”
Dona Constantine is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com
References:
1Young, Melissa, MD. (September 9, 2013). It's Unprofessional to Point Fingers in Patient Notes. Physicians Practice. https://www.physicianspractice.com/view/its-unprofessional-point-finger…
2Gardner, Keri, MD, MPH, FACEP. (August 1, 2018). Avoiding Chart Wars. Emergency Physicians Monthly. https://epmonthly.com/article/avoiding-chart-wars/
3Documentation Dos and Don’ts. Crico Staff. September 15, 2002. https://www.rmf.harvard.edu/clinician-resources/article/2002/documentation-dos-and-donts