Is SBNR’ code a red flag for malpractice?
Question: A manager recently brought it to my attention that some of our doctors sign records and then add "SBNR" after their names, meaning "signed but not read." This was forbidden at the last institution I worked at, but the doctors here insist that SBNR is a standard way for them to complete voluminous paperwork but protect themselves from liability if something on the record is in error. I think it’s a ridiculous practice that’s akin to not signing the record at all, but I’m meeting a great deal of resistance in trying to stop it. Should I stick to my guns on this?
Answer: You have good reason to worry about SBNR records, but you will find it very difficult to convince doctors that the practice is unacceptable. SBNR records are a time-honored tool for busy doctors worried about protecting themselves, not your hospital, from malpractice lawsuits.
A physician and attorney who specializes in representing plaintiffs in medical malpractice cases tells Healthcare Risk Management that he sees SBNR records all the time, and in some cases, uses them against the hospital. For the doctor, SBNR acts an escape valve that allows him or her to disavow details in the record, says Greig Coates, MD, JD, an attorney with Mithoff and Jacks law firm in Austin, TX. In some situations, the doctor’s disavowal means the hospital is left holding the bag.
SBNR is almost always associated with dictated records such as operative notes, Coates explains. The reasoning behind the SBNR notation is that the doctor has to sign the notes, but he or she does not have the time to sit and edit the printed version and ensure that it is precisely what was dictated or intended, with verbal errors corrected. The practice of using SBNR is widespread among physicians, Coates says.
From a doctor’s perspective, SBNR is useful and necessary; it is simply impossible for most physicians to carefully study each dictated report for errors, but they also don’t want to be held responsible for the transcriptionist typing "10 g" instead of "10 mg." Coates says that is the primary reason doctors use the notation and why they will be very resistant to a risk manager telling them not to.
But from a risk manager’s perspective, Coates says SBNR can be a real problem. "A conflict can arise, for instance, if the defendant physician is an emergency room doctor who’s not employed by the hospital," he explains. "When the finger-pointing starts, the doctor may say he didn’t really dictate what it says in the chart and use the SBNR as proof that he can’t be held responsible for the notes. It’s reasonable that a hospital risk manager would be much more comfortable with physicians committing to what they sign."
By itself, an SBNR notation does not prove anything. Medical records usually are quite redundant, so that any dispute about what actually happened can be resolved with a comparison of different citations. But the SBNR can be influential when a plaintiff’s attorney seizes on "inartful phrasing," for instance. If the phrasing doesn’t sound professional, the doctor can just deny saying it.
Though the use of SBNR in dictated notes is extremely common and acceptable to some degree, there is no real justification in using it for other types of documents, Coates says. Using SBNR on other types of records is going too far in an effort to provide an escape route, he says.
Eliminating the use of SBNR will be tough for a risk manager, he predicts. Nevertheless, he says it is a good idea for risk managers to take a firm stance and at least discourage it strongly. It will be difficult to eliminate with non-employee physicians, and he points out that you risk jeopardizing the contractor status by imposing such restrictions. But with employed physicians, Coates suggests that risk managers prohibit the use of SBNR and require physicians to take responsibility for the records they sign.
Otherwise, risk managers will be at a disadvantage even before a malpractice lawsuit is filed. Since a big part of your job is to assess the risk and liability of cases, a lot of SBNR notations means you never know quite where the responsibility will lie. When push comes to shove, will the doctor just disavow what’s in the record?
"I would want the doctors to stop doing this if I were a risk manager," Coates says.
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