Are some words always taboo in medical records?
Question: I’ve heard there are some words that never should be used in medical records because they are too concrete, too ambiguous, or otherwise just set you up for misinterpretation if the case results in a malpractice lawsuit. Is that true? What are the words?
Answer: Risk management professionals may differ on the details of which words are always dangerous to include in records, but most agree that some words are so problematic that they should be used very carefully, if at all. There is no single list of words that all risk managers would agree are taboo, and many of the terms will apply only to some specialties.
Some examples are provided by Richard Depp, MD, chairman of the department of obstetrics and gynecology at Jefferson Medical College in Philadelphia. At a recent conference sponsored by Symposia Medicus in Santa Fe, NM, Depp offered advice on some words that should be avoided when documenting high-risk obstetric cases. For instance, he suggests that doctors never document the words "emergency cesarean" or "stat cesarean." Those words could legally obligate the doctor to perform the cesarean section within 30 minutes, since the standard of care calls for action within that time frame for a true emergency cesarean.
However, many doctors use the term more loosely to indicate only that the cesarean is needed soon. And sometimes the doctor is aware that the cesarean should be performed as soon as possible, but the lack of personnel or equipment means it will not happen within 30 minutes. Using the loaded terms creates an unnecessary obligation, Depp says.
He also recommends avoiding the terms "fetal distress" and "asphyxia." The first is a commonly used term in the medical community, but Depp cautions that a lay jury can infer far more significance from the term than the medical professionals intended. Juries tend to think that "fetal distress" means the fetus is in immediate danger and may die soon if the problem is not corrected. That can cause the jury to envision a situation that was more urgent than it really was and use that perception to judge the staff’s actions. Instead of "fetal distress," Depp recommends documenting objective findings such as fetal heart rate patterns.
"Asphyxia" also is too vague a term to present to a lay jury, he says. A better option is to document the pH base deficit and CO2 measurements, along with more specific terms like "possible fetal acidosis" and "possible intermittent fetal hypoxia."
For more information, contact Richard Depp, MD, Department of OB/GYN, Jefferson Medical College, 111 S. 11th St., Philadelphia, PA 19107. Phone: (215) 955-6000.
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