Conflicts in chart? Expect attack on your credibility
Explain discrepancies in the medical record in real time
A discrepancy in the patient’s medical record is something that a physician defendant can expect a plaintiff’s attorney to take full advantage of.
“Plaintiff attorneys routinely look for chart discrepancies and inconsistencies,” says John Davenport, MD, JD, physician risk manager of a California-based health maintenance organization. “Even when they don’t have a direct connection to the allegation, they can be used as evidence of general carelessness and, at worst, untruthfulness.”
If two healthcare providers chart inconsistent information regarding the same patient, plaintiff’s counsel will use those inconsistencies to show that either or both providers were negligent and not paying attention, warns Linda M. Stimmel, JD, an attorney at Wilson Elser Moskowitz Edelman & Dicker in Dallas.
“When there is an obvious difference in the physician’s findings, I would recommend he explicitly note, ‘Though the nurse documented condition A, on re-examination the physician found condition B,’” says Davenport.
A nurse’s documentation might note something about the patient’s color, temperature, or vital signs, for example, which a physician’s charting done close in time doesn’t mention or describes in a completely different way. “This type of inconsistency may cause a jury to think a physician did not perform a complete exam or assessment,” says Stimmel. She advises physicians to review the nurse’s notes, and if discrepancies are noted, to discuss them with the nurse prior to charting, with future charting clarifying the inconsistency.
“Different opinions by different physicians can occur,” she says. “However, an effort to have a unified plan of treatment will make a strong defense in a lawsuit.”
If you disagree with another provider’s charting, resist the urge to criticize or correct the provider in the patient’s chart. “In my experience, criticizing other healthcare providers in the chart hurts both sides,” says Stimmel. “Use the chart to clarify your opinions so that you are protected, but chart objectively.”
In one case Stimmel defended, the physician charted that a nurse did not tell him of a change in skin assessment during a phone call, and if the nurse had done so, the physician would have come in to see the patient. “In the subsequent lawsuit, the nurse was alleged to be negligent for failing to inform the physician of all pertinent changes in condition,” says Stimmel. “In that same lawsuit, the physician was criticized for not asking the right questions of a nurse and accused of relying on nursing staff for medical diagnosis.” (See related story on avoiding inaccurate charting in EMRs, below.)
For more information on discrepancies in the patient’s medical record, contact:
- John Davenport, MD, JD, Irvine, CA. Phone: (714) 644-4135. Email: Doctordpt@cox.net.
- Linda M. Stimmel, JD, Wilson Elser Moskowitz Edelman & Dicker, Dallas. Phone: (214) 698-8014. Fax: (214) 698-1101. Email: firstname.lastname@example.org.
Your EMR charting might be provably false!
Physicians should not document impossibilities
Does your electronic medical record (EMR) indicate that you performed a full neurological examination for a patient who presented with a sore throat, cold, and headache?
Entering an overly complete history and examination on a patient presenting with a minor or simple complaint is one danger with EMRs, especially when time-stamping makes such a lengthy examination unlikely, warns John Davenport, MD, JD, physician risk manager of a California-based health maintenance organization.
Carelessly documented impossibilities can make a physician defendant appear untrustworthy. “In one recent case, a full preoperative clearance exam was entered and documented more than 20 minutes before the patient was documented to have arrived,” reports Davenport.
Plaintiff attorneys have several goals in examining the patient’s medical record, he explains. “The first is to find documentation that you acted below the standard of care,” he says. “The second is to show that you are careless. The third, and one of the most powerful, is that you are not truthful.”
EMRs “easy to abuse”
While EMRs are more efficient than paper charting, some of the factors that make them easy to use also make them “easy to abuse,” says Davenport. “Such full and automated documentation sometimes leads to discrepancies in the chart.”
For example, an automated phrase documenting a patient’s pelvic exam with notation of a normal cervix is not credible in a patient who has had a full hysterectomy.
Davenport says he has seen an obviously incorrect finding entered into the chart become an issue many times in medical malpractice litigation, such as a male-specific exam performed on a female patient, and inappropriate responses to clearly abnormal laboratory or X-ray findings.
“A plaintiff attorney might ask both the plaintiff and the defense expert if the medical standard of care required accurate charting, followed up by a question if the defendant’s charting was accurate,” says Davenport.
Inaccurate charting makes the physician defendant’s charting weaker and the case more likely to be settled, he adds. “When one or two keystrokes can populate a complete and thorough note, there is the risk of accidentally or carelessly entering false documentation into a patient’s chart,” Davenport says. “Such entries can lead to an attack on the physician’s credibility.”