All Content

Note to Self: Document Wisely


One patient was as “fat as a whale,” according to his medical record. A patient who fell out of bed at night had “a nocturnal misadventure,” according to his chart, which provided no further information. Another medical record stated that a patient had been seen without the physician reviewing previous documentation. Yet another chart says the doctor referred the patient to a physician whose “credentials he was unsure of.”

Whether humorous or serious, medical records all too often include inappropriate information. While some of it may seem merely tasteless or silly, inappropriate remarks can cause serious problems—medical, legal, regulatory, and financial.

Because records are critical in so many areas of medical practice, hospitalists need to work harder to ensure they are accurate and appropriate. Experts say there should be more training in documentation.

“Doctors are trained to think about clinical and legal issues in documentation, but far less about the regulatory and billing aspects,” says David Grace, MD, area medical officer for The Schumacher Group, Hospital Medicine Division, in Lafayette, La., who saw the records of the obese patient and the one who fell at night.

As area medical officer, Dr. Grace reviews records and is developing a fellowship for Schumacher’s hospitalists in which documentation will be taught early on. “You have to teach doctors how to be hospitalists, and proper documentation is critical,” he says.

Patrick O’Rourke, an attorney for the University of Colorado, Denver, and legal columnist for The Hospitalist, also believes doctors need more training in documentation. He works with them on that in order to help them “stay out of court.”

Document for Billing, Compliance

One key area is documenting patients’ conditions thoroughly upon admission so reimbursement is not denied because it is assumed a condition developed during hospitalization.

For example, document conditions like pressure ulcers that could develop into bedsores or urinary infections that could be traced to a catheter.

“There’s tension between documenting to support billing/coding and for the best medical care because it can make it less clear what the most pressing medical problem is; both are important,” says John Nelson, MD, a partner in Nelson Flores Associates, a hospitalist consulting firm.

Dr. Nelson, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., and a co-founder and past president of SHM, says doctors have to find the balance.

“Just documenting for one would be like staring at the speedometer and gas gauge while you’re driving,” he cautions. “You won’t speed or run out of gas, but you may hit a wall.”

Dr. Nelson believes templates can be helpful, particularly for coding and billing. He urges physicians to always think about what they need to report that is not in the template.

Dr. Li’s group takes very seriously the need to use templates as guidelines only. “For example, the detail of the history and present illness is not templated,” he says. “The patient’s story, when the problem started, what made it better, worse, etc. must be written out.”

There are things physicians don’t need to write out, he says. For example, using a pain scale is effective on a template and the assessment of pain and the documentation of its treatment is very important to the Joint Commission, he says.

“A template is a tool to help you document more efficiently,” Dr. Li says. “The point is to do whatever you need to do to provide for other providers, legal documentation, and billing.”—KF

The Courtroom

O’Rourke, who has worked on medical malpractice cases for his university’s Health Sciences Center and in private practice for 11 years, says the most common inappropriate wording he sees is back-handed denigration.

“Phrases like ‘hysterical’ or ‘oversensitive,’ ” he says. “Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.”

O’Rourke also says while most physicians are good at documenting what they did or saw, they don’t usually do a lot to explain why. “Making clear your thought process is good in court, in part because doctors often don’t remember a lot years later in front of a jury.”

Documentation should reflect the process of differential diagnosis, O’Rourke says. “If a patient is having difficulty breathing, for example, it could be pneumonia, reactive airway disease, allergies, or a cold. The record should explain the basis for the doctor’s diagnosis and treatment actions.”

Never go back and change records—that undermines their credibility with juries, O’Rourke advises. “You have to make corrections with an addendum, the date and time, and reason for the change,” he says. “Since records go to insurers and other providers, they have to match. In court, the doctor really loses credibility when they don’t.”

It’s also risky to overuse medical abbreviations, says O’Rourke. “A recent study found that 5% of 30,000 medical errors were due to medical abbreviations.” He notes that the Institute for Safe Medication Practices has a list of error-prone abbreviations, symbols, and dose designations on its Web site (


Another big problem with documentation is legibility, says O’Rourke, noting that many lawsuits have arisen from wrong medications and dosages. “Illegibility causes many medical errors that are preventable,” he says.

“Physicians must remember that just because they can read their writing doesn’t mean others can,” says O’Rourke. “Doctors think the records are their records, but they’re really the patients’ records. If other doctors, pharmacists, etc., can’t read them, why make them?”

Joseph Li, MD, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston, also says illegibility is a big problem. “Physician signatures must be legible,” he notes. “It’s critical to know who wrote the notes. If someone doesn’t know something or can’t read something, they can find out.”

Yet “just telling physicians to write legibly doesn’t work,” says Dr. Li, who is also an assistant professor at Harvard Medical School. “Doctors need to print their name beneath their signature.”

Dr. Li’s group uses templates for admission and progress notes. They include the names of each physician with a check box so they can indicate who wrote the notes. “This is how we comply with that guideline from the Joint Commission on Hospital Accreditation,” he says.

Robert Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, has reviewed malpractice cases for hospitals and lawyers and in his current role focuses on deficiencies in documentation. He has seen numerous kinds of inappropriate information in medical records. Among his suggestions:

[Avoid] phrases like “hysterical,” “oversensitive.” Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.

—Patrick O’Rourke, an attorney for the University of Colorado, Denver

Don’t try to settle a dispute in a chart. Dr. Rohr recalls a patient who had a leaking abdominal hernia. A resident wrote in the chart the patient should have surgery within six hours or he would die. The surgeon disagreed. The patient lived without having surgery within the six hours, but if the case had been litigated, the chart note could have been used against the surgeon. “Settle things face to face or on the phone. The medical record must only detail your best thinking about the patient,” says Dr. Rohr. “Don’t be speculative. Agree on a course of action with other physicians and make documentation represent the agreed-upon plan. Showing differences of opinions helps plaintiffs’ lawyers.”

Don’t use charts as note pads for drawings, doodles, or other extraneous markings. “Nothing should be on the record that doesn’t help the next physician care for the patient,” says Dr. Rohr. “It makes the chart look unprofessional. Not good in court or anywhere else.”

Don’t leave the impression that you haven’t done a complete exam. Dr. Rohr saw the documentation that says a patient was “seen without chart.” Instead, he says, doctors should collect as much history as possible. “There are other ways to get information,” he asserts. “Doctors should shy away from making statements in charts about what isn’t available. Instead, outline all the information that is.”

Don’t just run through standard descriptions. Give a specific description of what you have actually examined and then state that “no other abnormalities were seen.” Errors and inappropriate information often go into records within standard exam information, Dr. Rohr and others say.

Avoid controversy in the chart—or, in Dr. Rohr’s words, “Don’t confess to malpractice.” “Don’t put things in charts that indicate you haven’t given the patient your best,” he says, recalling the physician whose chart mentioned a referral to a physician with uncertain credentials.

Be careful in documentation about whether a patient can afford a treatment. Payment issues should be worked out elsewhere. “You are in jeopardy if you give a patient less treatment because they can’t pay for it,” he warns. “It would look bad to a jury. You can include that a patient refused a treatment, but you don’t have to say why.”

Be as complete as possible, including all pertinent detail of a patient’s history. “You need to be thorough for the medical professionals who will treat the patient after you and you need to note certain conditions accurately for appropriate payments to physicians and facilities.” That need to create records that serve regulatory and billing purposes is becoming increasingly important to physicians and hospitals. TH

Karla Feuer is a journalist based in New York.

Next Article:

   Comments ()