Frustrated with a patient? Don’t let it show in chart
Otherwise you might lose case that is otherwise defensible
While most physicians would think twice before using strong, unflattering language to describe a colleague in a patient’s chart, they might not exercise the same degree of caution when documenting their impression of their patient.
“In my experience, inflammatory characterization of a patient is never helpful in defending a case. It should be avoided as a matter of practice,” says Joshua M. McCaig, JD, an attorney with Polsinelli Shughart in Kansas City, MO.
McCaig handled two cases in which an upset patient acted rudely during an office visit and the physician documented the events. “In one case, the physician used words like ‘immature’ and ‘babyish’ to describe the patient, yet never described a reason for the patient’s actions,” he says.
“Instead of walking into the deposition confident about his care, the physician was immediately required to defend his choice of words and his characterization of the patient. Eventually, he was backed into a corner and admitted his choice of words was poor,” says McCaig. “More than just make him look bad, this called into question his ability to appropriately document information.” Since the defense of the case hinged on the information in the records, the patient’s attorney attempted to infer to the jury that the physician’s records were untrustworthy.
Patient behaved violently
In the second case, the physician was called into a difficult situation in which a patient was behaving violently in the clinic and using inappropriate language toward the staff. After dealing with the situation, the physician wrote an objective note with no colorful language, documenting why the patient was upset and the steps that were taken to deal with the situation. “When it came time for deposition, this physician simply relied upon his note to describe the incident,” says McCaig. “He came across as being professional and level-headed. This is a quality a jury looks for in a physician, and, needless to say, we were able to use this to our advantage.”
The case with the good record eventually was dismissed without payment, and the case with the poor documentation was settled. “The bad note did play a part in our overall consideration for settling the case. It did not help the overall posture for defending the case,” says McCaig.
Although the primary purpose of a medical record is to document patient care, during litigation a medical record provides the jury with insight into the character of the physician, says McCaig.
“The significance of medical records can never be overstated,” he emphasizes. “Through the details within the notes, the juror forms an opinion about the physician’s attention to detail and his or her professionalism.”
Regardless of the situation confronting a physician, medical record charting always should be objective, says McCaig. The average juror expects a physician to be a caring professional who is devoted to healing the sick, he explains, and once the juror forms a negative perception of the physician, it is difficult to undo.
“Whether or not the physician is liked by the jury often makes the difference in the verdict,” says McCaig. “While a typical juror wants to believe and like a physician, he or she is also looking for a reason to give a sympathetic plaintiff money.”
Source
For more information on objective documentation, contact:
- Joshua M. McCaig, JD, Polsinelli Shughart, Kansas City, MO. Phone: (816) 395-0651. Fax: (816) 374-0509. Email: [email protected].
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