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| Defensible Documentation: What you need to know |
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by Marcos A. Vargas, MSHA, PA-C - March 14, 2011
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In any alleged medical malpractice case, aside from the obvious (case strengths or weaknesses, potential egregious breaches), plaintiff attorneys also look for potential red flags on the medical record such as…ineffective charting or communication lapses among providers...care-giving mishaps… and missing or incomplete charting/documentation…finger pointing…staff attitudes…illegible documentation, or scanty notes, etc.
Aside from those medical chart “red flags” what else do plaintiff and/or defense attorneys look for specifically when sifting through the medical chart?
They both look for a common denominator: a solid, defensiblemedical record. While poor documentation isequated with non-defensibility –and rightfully so—it can mean many things to different people.
The liability controversy always seems to hover around the perennial question of what is “poor documentation”. In most instances it has nothing to do with how much is too much or how scant is too scant, even though most clinicians feel that’s what poor documentation means. Regardless of whether you’re a crammer or a scanty documenter, the issue transcends beyond that. In fact, for all practical purposes, the question should be: are you a defensible documenter or are you poor documenter - one who doesn’t document their Clinical Decision making process succinctly and clearly in the medical chart?
While some Risk Management Professionals argue that you can never document too much, others are just as quick to point out that “too much documentation” is counterproductive. They would argue that documenting “everything” needlessly would provide the plaintiff’s attorney with evidence or “ammunition”-- to be used against you in a malpractice case.
However, and despite the controversy, most agree that regardless of which camp you may subscribe to, the clinician ultimately should see this as an opportunity to document contemporaneously how or what medical care provided and also, more importantly, an opportunity to educate all others of the what, the how and the why and thewhen the provider arrived to a particular set of conclusions regarding the diagnosis, and/or plan of care, etc.
Avoidance of sketchy or scant documentation surely boosts your defensibility of your provided care, but more importantly, it raises your professional credibility when stating clearly and succinctly what features of the history and/or physical findings steered you in the direction undertaken and/or conclusions arrived at.
For instance, detailing your reasoning as to why you chose to forego antibioticsor why you withheld a diagnostic study will not only show that you considered the benefit-risk ratio of a specific intervention, but that you also didn’t close the diagnostic process prematurely.
And therein lays the nugget of how to avoid poor documentation practices/allegations commonly raised in lawsuits against clinicians when an adverse outcome occurs.
In sum, scant or sketchy medical records can be considered malpractice cases waiting to happen, particularly if the patient suffered an injury.
In contrast, if your care was in line with the clinical presentation, if you acted as a responsible steward of the medical resources at your disposal and you showed this by explicitly outlining or explaining briefly your clinical decision-making process (along with a Differential diagnoses, etc.), then you not only boosted your defensibility by providing quality care medical entries but you avoided the worst documentation labeling know to an attorney— being a poor documenter.
 Marcos A. Vargas, MSHA, PA-C is a Boston born and Puerto Rican bred individual who has an extensive healthcare industry background, both industry-related as a Pharmacy Technician during his undergraduate years, and industry-specific as a dually N.C.C.P.A. certified Physician Assistant in Surgery and Primary care after graduating from the University of Alabama—Birmingham Physician/Surgeon’s Assistant Program. He has held clinical positions in Cardiothoracic, General Surgery, & Emergency Medicine over the past twenty years. He holds a Master’s in Science Administration from Central Michigan University and a Healthcare Risk Management graduate certificate. He has been retained and consulted regularly by both plaintiff & defense law firms over the past 14 years. During this time, he has served as both a consulting medical reviewer and a PA expert. Marcos has lectured on Clinical Risk Management (PA) issues throughout the years to various Michigan-based PA Training Programs. He has done the same for lay audiences, covering a wide range of “Wellness” topics. He has been a supporter and associate member of numerous professional clinical and non-clinical organizations. Currently he is employed as an orthopedic PA at HMC.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Marcos A. Vargas, MSHA,PA-C (Flushing,MI) |
on 22 Mar 2011 at 1:38 pm |
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Thanks for the feedback Bob--greatly appreciated. Would definitely entertain the sugeested idea and recommendation.
For those interested in reaching me, I can be contacted @ maravarpac@hotmail.com (my personal e-mail address) |
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| Bob blumm (amityville, NY) |
on 16 Mar 2011 at 10:59 am |
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| A well written article where I can agree with both aspects but the real focus is in letting the lawyers know your thought process. this takes specific training and I suggest a small bookleet that can make it through the publishers hands quickly and assist 230,000 NP/PA clinicians. |
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