Does documentation really save you in court?

[MedicineZ0Z]

Cause it's still your word against theirs.

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[calvnandhobbs68]

Cause it's still your word against theirs.

It’s not your word against theirs most of the time in the first place.

 

[Goro]

Cause it's still your word against theirs.

During my entire professional career, I have been told repeatedly to "document everything"

Because those documents WILL save your ass when in court. I have seen this first hand with students who tried to sue our school. Note the words "tried to".

 

[Mass Effect]

Cause it's still your word against theirs.

Except if they die and their family wants to know why you didn't order ___ test. When you document that there was no indication for ___ test based on your physical exam (as documented) and on the patient's subjective report (as documented), it WILL save you in court. If you didn't document that exam or the patient's report, you're screwed.

This is especially true in my field - psychiatry. If a patient commits suicide a day after he/she sees me, I better be able to turn to my note and see that I had no concerns at the time of his/her visit because the patient was not suicidal and his risk assessment (access to weapons, social supports, history of suicide attempts, etc, etc, etc) didn't indicate any elevated acute risk of self-harm. If I can't do that, I'm likely going to lose or settle the case if family decides to sue.

 

[dpmd]

Cause it's still your word against theirs.

Not really. If you didn't document it then it is your word against theirs. If you did it is their word against the written document that they have to prove is incorrect if that is what they believe.

 

[Frazier]

It mainly keeps you OUT of court.

If you have an ironclad note, the patient still may want to sue you -- but the experienced medmal lawyer wont be interested in the case.

 

[Vandalia]

Yes, it will save you, because the documentation is contemporaneous. Statements that you make or justifications that you make after a suit is filed will always be judged with suspicion. In the same way, a patient's statements after a bad outcome will be judged with suspicion by the trier of fact. However, documentation made before any of these things happen is given great weight.

If the medical record says something was done, it was done. If it doesn't record an act being done, it was not done. There is an incredible burden on the opposite party to overcome this presumption.

 

[AMEHigh]

Documentation will save/help you in a lot of cases, not just medicine. So yes document, document, document.

 

[AdmiralChz]

We had quarterly malpractice rounds in residency where we reviewed open lawsuits in my specialty. The takehome point EVERY time was documentation, documentation, documentation.

Yes, YES it undeniably saves you in court. Keeps you out and keeps your malpractice carrier happy.

 

[Ironheme]

We had quarterly malpractice rounds in residency where we reviewed open lawsuits in my specialty. The takehome point EVERY time was documentation, documentation, documentation.

Yes, YES it undeniably saves you in court. Keeps you out and keeps your malpractice carrier happy.

Where did you end up finding the cases?

 

[AdmiralChz]

Where did you end up finding the cases?

Presented by faculty, not sure where they found them a few were personal experience.

Our malpractice carrier puts out a monthly newsletter with cases and good reviews on legal issues. Documentation a HUGE component.

 

[Sardonix]

Presented by faculty, not sure where they found them a few were personal experience.

Our malpractice carrier puts out a monthly newsletter with cases and good reviews on legal issues. Documentation a HUGE component.

I like to imagine it starts out along the lines of, "JC... for the last time STOP DOING THIS CRAP."

 

[Mass Effect]

We had quarterly malpractice rounds in residency where we reviewed open lawsuits in my specialty.

This is a fantastic idea. Do a lot of residencies do this? I wish we did it when I was a resident.

 

[AdmiralChz]

Here’s an example from one of our rounds:

Patient came for ERCP, history of numerous orthopedic and spinal complaints. Afterwards pt brought suit to anesthesiologist and GI for hand/arm weakness which pt believed was due to inadequate padding with lateral positioning - it was a huge suit for a lot of money as patient claimed they could no longe work.

Documentation saved them with simple things like - “patient moved self into lateral position of comfort, all pressure points padded, no complaints before induction of anesthesia”

Lawsuit was dismissed and the plaintiff had to pay malpractice attourney fees.

 

[FutureInternist]

Alternatively, too much documentation can also be suspicious.

Just had an arbitration case where the surgeon wrote on physical exam “no carotid bruit, no JVD, no thyromegaly etc”. on EVERY note for 6 days.

Pt stated that the surgeon “never touched her” after the procedure and just “stood at edge of bed”.

Don’t know of any surgeon who would check carotid bruit or JVD EVER, much less daily.
Similarly, who the F checks for thyromegaly daily?

That piece of fiction nullified everything else the surgeon had written or said in the proceeding.

Vote was 6-0 against the doc.

First time I voted against... couldn’t sleep for 2 days but god dang the surgeon F’d up.

 

[rokshana]

Alternatively, too much documentation can also be suspicious.

Just had an arbitration case where the surgeon wrote on physical exam “no carotid bruit, no JVD, no thyromegaly etc”. on EVERY note for 6 days.

Pt stated that the surgeon “never touched her” after the procedure and just “stood at edge of bed”.

Don’t know of any surgeon who would check carotid bruit or JVD EVER, much less daily.
Similarly, who the F checks for thyromegaly daily?

That piece of fiction nullified everything else the surgeon had written or said in the proceeding.

Vote was 6-0 against the doc.

First time I voted against... couldn’t sleep for 2 days but god dang the surgeon F’d up.

Even I don’t check the thyroid daily...and I check everyone’s thyroid!

 

[dpmd]

Somebody had a stupidly set up template.

 

[FutureInternist]

Somebody had a stupidly set up template.

We asked him about that.
He said he used Dragon to dictate all of his notes.... which makes it even more suspicious, like why would you not admit to copy/pasting?

 

[operaman]

Yeah I think of documentation as keeping OUT of court rather than helping IN court. My feeling is that once you’re in court, everybody loses but the lawyers. But as noted above, solid documentation will get reviewed by prospective attorneys and their own medical reviewers and they won’t even bother filing in the first place.

While nothing can save you from a true screw up, most suits are filed for things that are not actually malpractice. It’s often a bad outcome but within the realm of expectation. The way they sue you is for lack of informed consent, saying they’d have never had X surgery or taken Y drug or had Z test if they’d known. This is a place where documentation is absolutely key. Even some allegations of actual malpractice - things like failure to diagnose - can be saved by documentation. If you’ve thoughtfully considered a diagnosis but ruled it out based on your findings at the time, that can save you even if they ultimately end up having that thing.

I love the idea of malpractice rounds and I may actually try starting that in my own program. I have federal and state court logins so maybe I can even pull old suits filed against my own institution. I highly encourage people to read some filings and see how lawyers interpret what we do and document every day.

 

[dpmd]

We asked him about that.
He said he used Dragon to dictate all of his notes.... which makes it even more suspicious, like why would you not admit to copy/pasting?

Can't you insert a templated portion with dragon? I don't use it but I thought you could. So not a copy paste but a "insert follow up exam" kind of problem.

 

[sluggs]

Perspective: I used to be an attorney who did a lot of med mal defense and for a year I also tried plaintiff med mal cases (now IM/CCM)-- Nothing is worse than over-documentation or a paranoid rambling note that sounds scared or defensive. Document the problem list and what you are doing-- update as new info comes to light. Don't worry or even think about lawsuits... they are very random. Practice good medicine and stay cool

 

[Ironheme]

Can't you insert a templated portion with dragon? I don't use it but I thought you could. So not a copy paste but a "insert follow up exam" kind of problem.

yes you can.

 

[MedicineZ0Z]

Perspective: I used to be an attorney who did a lot of med mal defense and for a year I also tried plaintiff med mal cases (now IM/CCM)-- Nothing is worse than over-documentation or a paranoid rambling note that sounds scared or defensive. Document the problem list and what you are doing-- update as new info comes to light. Don't worry or even think about lawsuits... they are very random. Practice good medicine and stay cool

Kind of what I was getting to I think.

Some staff really want extremely detailed super long notes. Gets annoying cause more of it is repetitive and jargon.

 

[FutureInternist]

Kind of what I was getting to I think.

Some staff really want extremely detailed super long notes. Gets annoying cause more of it is repetitive and jargon.

We have some docs who document Severe sepsis, AKI, leukocytosis, lactic acidosis etc all as separate bullet points in their notes..... and then copy paste the same plan into each one !!!

 

[Raryn]

We have some docs who document Severe sepsis, AKI, leukocytosis, lactic acidosis etc all as separate bullet points in their notes..... and then copy paste the same plan into each one !!!

On the one hand, there is a benefit from documenting the separate diagnoses - it lets you appropriately portray how ill the patient is and potentially code at a higher level.

For example, if I have a patient with panhypopituitarism, I could diagnose E23.0 (hypopituitarism) and leave it alone. Or I could diagnose separately central hypothyroidism, adrenal insufficiency, growth hormone deficiency, and diabetes insipidus. Only the latter appropriately portrays the complexity of the case.

On the other hand, there's no reason to copy/paste the same plan into each one. You can just put them all together and put the plan underneath them as a whole OR just write the plan under the top one and then write "see above" for the remainder.

 

[FutureInternist]

.....On the other hand, there's no reason to copy/paste the same plan into each one. You can just put them all together and put the plan underneath them as a whole OR just write the plan under the top one and then write "see above" for the remainder.

This is what I do.
Put all associated dx’s together and just write the plan once

 

[Merely]

Alternatively, too much documentation can also be suspicious.

Just had an arbitration case where the surgeon wrote on physical exam “no carotid bruit, no JVD, no thyromegaly etc”. on EVERY note for 6 days.

Pt stated that the surgeon “never touched her” after the procedure and just “stood at edge of bed”.

Don’t know of any surgeon who would check carotid bruit or JVD EVER, much less daily.
Similarly, who the F checks for thyromegaly daily?

That piece of fiction nullified everything else the surgeon had written or said in the proceeding.

Vote was 6-0 against the doc.

First time I voted against... couldn’t sleep for 2 days but god dang the surgeon F’d up.

I don’t understand how this is strange or odd. Maybe it’s where I work but everyone I know makes up the physical exam, you guys think everyone is doing a full physical exam when they document that? I’ve seen so many people copy and paste the physical exam and they do maybe 1/2 of what they write

 

[FutureInternist]

I don’t understand how this is strange or odd. Maybe it’s where I work but everyone I know makes up the physical exam, you guys think everyone is doing a full physical exam when they document that? I’ve seen so many people copy and paste the physical exam and they do maybe 1/2 of what they write

Perhaps like speeding, many people may do it but not everyone gets caught.
But if you do, its falsifying medical records.
I do heart, lungs and abd on everybody and then the Dx specific exam, although a majority of the time, its covered by the above.

There was also a new CBT that we did that talked about justifying a more extensive exam or ROS.....like why are you checking reflexes on a COPD exacerbation, or asking about hematemesis in a CVA pt?

 

[dpmd]

I don’t understand how this is strange or odd. Maybe it’s where I work but everyone I know makes up the physical exam, you guys think everyone is doing a full physical exam when they document that? I’ve seen so many people copy and paste the physical exam and they do maybe 1/2 of what they write

You gotta be slicker than that though. The patient knows whether you put a stethoscope on a body part or not. Just document **** that is easily visualized from the door plus whatever you actually touched.

 

[dpmd]

Also, why put useless **** like that in your postop note? You aren't billing for it so just talk about what you care about, like the incision.

 

[FutureInternist]

Also, why put useless **** like that in your postop note? You aren't billing for it so just talk about what you care about, like the incision.

Exactomundo... which is why his whole testimony about pt not verbalising any complaints to him, him looking at surgical site (when that was the one thing that wasn’t well documented), and pt being non tender on exam were taken with a TON of salt

 

[AMEHigh]

This is what I do.
Put all associated dx’s together and just write the plan once

When I was in residency on inpatient service the attendings told us to do this for billing purposes to show how sick the patient is to justify staying in the hospital and getting paid appropriately. With our old EMR you could list diagnoses together but when we switched to Epic that was no longer possible. So annoying.

 

[Mass Effect]

Kind of what I was getting to I think.

Some staff really want extremely detailed super long notes. Gets annoying cause more of it is repetitive and jargon.

Actually, your question was whether documentation will save you since it's your word against theirs. This is an entirely separate question. No, you should not repeat yourself over and over and over again, but I have yet to see anyone make a logical argument against detailed notes, assuming you did everything you document. Rambling notes are not good nor are notes where you go on and on and on for 4 paragraphs about one part of the exam, but in general, you document what you did/said to the patient.

When I was in residency on inpatient service the attendings told us to do this for billing purposes to show how sick the patient is to justify staying in the hospital and getting paid appropriately. With our old EMR you could list diagnoses together but when we switched to Epic that was no longer possible. So annoying.

Why is it not possible with Epic? We use Epic and there's a line for diagnoses. I put them all there. Then below that, I document my plan.

 

[Raryn]

Actually, your question was whether documentation will save you since it's your word against theirs. This is an entirely separate question. No, you should not repeat yourself over and over and over again, but I have yet to see anyone make a logical argument against detailed notes, assuming you did everything you document. Rambling notes are not good nor are notes where you go on and on and on for 4 paragraphs about one part of the exam, but in general, you document what you did/said to the patient.



Why is it not possible with Epic? We use Epic and there's a line for diagnoses. I put them all there. Then below that, I document my plan.

It depends on how you're documenting in EPIC. If you are just free texting a note, you can do whatever. If you're documenting your plan under the problem list and then importing that into the note (which is something many hospitals are requiring because it makes you keep your coding in the problem list up to date) it gets more difficult.

 

[AMEHigh]

Actually, your question was whether documentation will save you since it's your word against theirs. This is an entirely separate question. No, you should not repeat yourself over and over and over again, but I have yet to see anyone make a logical argument against detailed notes, assuming you did everything you document. Rambling notes are not good nor are notes where you go on and on and on for 4 paragraphs about one part of the exam, but in general, you document what you did/said to the patient.



Why is it not possible with Epic? We use Epic and there's a line for diagnoses. I put them all there. Then below that, I document my plan.

Maybe your epic is different? (I just
moved to a new health system and it’s definitely a lot different than my other one but I’m only doing out patient now).

In that epic you could put 1 diagnosis on a line essentially and then fill in the assessment and plan below, rinse and repeat. Obviously for the assessment and plan part you could put "see plan above" for things that were repetaticd and not just copy/paste the same plan over and over. However, there was no way to put 3 different diagnoses on 1 line when you clicked to pick the diagnoses. Each problem number had capability for 1 diagnosis only.
Problem 1. Hypokalemia
Problem 2. Hyponatremia
Problem 3. Sepsis

In our old EMR you could literally put hypokalemia, hyponatremia, sepsis all in the same line/same problem with the A/P below.

The joys of EMR!

 

[thepoopologist]

Cause it's still your word against theirs.

Its your documented word at the time of the exam versus their word following an allegedly adverse event after the exam.

The difficulty is documenting accurately and consistently across your census while avoiding phrases that could be picked apart in court.

 

[FutureInternist]

When I was in residency on inpatient service the attendings told us to do this for billing purposes to show how sick the patient is to justify staying in the hospital and getting paid appropriately. With our old EMR you could list diagnoses together but when we switched to Epic that was no longer possible. So annoying.

I put all the acute issues as high priority and all chronic ones as low, so in your note Epic does put them in that order (that takes are of bling), then I just dictate each problem list that goes together (Sepsis, AKI, UTI) and write one plan underneath them.

With the Spring 2019 upgrade, Epic can do Problem Based Charting as well, where you can collect associated dxs together and then document in the “Overview” section of problem list, and then import that into your note

 

[Groove]

Yes, it can save your ass. I love how attorneys can recommend to keep things simple and concise when the reality is that your note gets dissected and timestamped back to the Jurassic era. If you over document, they'll find a phrase or contradiction to focus on. If you under document, they'll imply and ask why you didn't document something. I say better to document thoroughly and I'd rather over document that under document because many times these cases are getting reviewed by a peer who's job is to tell the malpractice attorney whether the case has merit or is worth pursuing.

There's nothing wrong with using templates, just add/subtract a few things depending on the particular pt and their cc/exam. I also have a "visual exam" where I'm not necessarily touching the pt. We use Cerner and if I had to click everything, every time I see a new pt, I'd never get any work done.