"What Was EP Thinking" Is Pivotal During Suit
Dictation is best at this
With some electronic medical record (EMR) documentation systems, plaintiff's attorneys may have a difficult time determining what actually happened during the ED visit.
"To the extent they cannot figure out what is going on, it might be good for the EP if it confuses the issue," says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. "Nonetheless, I am not a big fan of the EMRs or anything except a dictation because it so poorly explains the medical decision-making."
Lawrence says that he has a strong personal bias for dictation, because it allows for a more individualized description of the patient encounter.
"Even though it may seem like a routine diagnosis, there may be something about the patient you want to document that doesn't fit inside a neat, prefabricated form," he says. "Dictation allows for all the variabilities."
Dictated records allow the EP to explain in great detail all of the diagnoses being considered, such as thoracic and dissecting aneurysms, myocardial infarction, cardiac tamponade, and pneumothorax for a chest pain patient, and the reasons why each of these was ruled out.
"Of course, none of this will protect you if you are wrong," adds Lawrence. "Nonetheless, if you are a halfway reasonable physician, the fact that you missed something can still be defended because you were thinking the right way. You can't do that on anything but a dictated chart."
Lawrence says he is always pleased to see a dictated chart when he reviews medical records for attorneys. "I always breathe a sigh of relief because I know exactly what the doctor is thinking," he says. "The only downside is that if there are mistakes, then you have documented that really well."
On the other hand, Lawrence says he finds it difficult to determine what the EP was thinking with standardized forms. "I find those to be the weakest charts to try to defend," he says. "Also, it leaves you open to criticism as to why you didn't check or circle something."
For more information, contact:
Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary's Medical Center, Long Beach, CA. Phone: (562) 491-9090. E-mail: firstname.lastname@example.org.