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.”
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.
