Do interns' progress notes bear any weight?

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I understand that writing a thorough progress note is a good training. However, interns are way too busy running all the errands and sometimes are not able to include all the information in the notes for every patient. In case there is a lawsuit and the chart is scrutinized,will any missing information or any incorrect understanding of the plan of care in interns' progress notes bear any legal consequences?
(BTW, many attendings' notes are so concise/short.)

 

[Law2Doc]

I understand that writing a thorough progress note is a good training. However, interns are way too busy running all the errands and sometimes are not able to include all the information in the notes for every patient. In case there is a lawsuit and the chart is scrutinized,will any missing information or any incorrect understanding of the plan of care in interns' progress notes bear any legal consequences?
(BTW, many attendings' notes are so concise/short.)

Absolutely. You are a physician and your notes are part of the medical record. A lawyer will be entitled to present these notes to a jury and create whatever inferences he deems beneficial. You don't get a bye because you are "too busy running all the errands".

 

[Smurfette]

Quite Possibly. Part of being an intern/resident is learning what and how to document. Omitting something *could* come back to bite you (or your attending) later on. This doesn't mean you need to put every single little thing in your note, but to be able to recognize what components are crucial for supporting your management decisions.

 

[P Diddy]

I understand that writing a thorough progress note is a good training. However, interns are way too busy running all the errands and sometimes are not able to include all the information in the notes for every patient. In case there is a lawsuit and the chart is scrutinized,will any missing information or any incorrect understanding of the plan of care in interns' progress notes bear any legal consequences?
(BTW, many attendings' notes are so concise/short.)

Attending notes are concise because the documentation for billing should have been done in the resident note. I will state in my anecdotal experience that the better attendings write more comprehensive notes (ie, not just"'I saw and examined the patient...").

But aside from billing and legal purposes, intern notes are important. Everything you do is an audition. Notes are a way to show your capacity to reason based on the available data and your ability to convey information concisely and accurately. These are essential skills for physicians (perhaps not surgeons, jk, I see the best surgeons as both technically gifted and the best thinkers).

p diddy

 

[Top Gun]

Absolutely interns' notes bear weight. You don't get a free pass just because you're busy and in training. If there is a malpractice suit, more than likely the interns' notes will be subpoenaed. In fact, in a teaching hospital, many times the intern will write a note and the attending will write a quick one-liner saying "Discussed with intern. Agree with plan above." I don't do this because, one, I don't have any interns or residents, and two, because writing the progress note out helps me think through the assessment and plan better. However, interns are generally expected to write a more comprehensive note because they're inexperienced. They have to do a more thorough job of demonstrating their reasoning than a seasoned attending.

 

[Chakrabs]

Important or not, take some pride in yourself and write as good and comprehensive a note as possible. Thats what I try to tell myself when I'm swamped with work and am scrawling out all my notes before rounds begin!

 

[KnuxNole]

That's kinda scary if med students write a note, gets "signed" by a resident who doesn't read it, and a lawsuit comes and finds out it is missing five thousand things and the resident gets all the blame.

 

[Mattchiavelli]

That's kinda scary if med students write a note, gets "signed" by a resident who doesn't read it, and a lawsuit comes and finds out it is missing five thousand things and the resident gets all the blame.

Every place I am med student generated notes (as in first author does not have a license/provisional license) are not billable so unless your service is completely out of it The intern note is really where it all begins medico-legally speaking and also businesswise. Med students are students and if you have a Dr in front of your name it's time to put on the big person underwear and write some real notes that other medical professionals can use to base medical decisions on because (esp if you're using an EMR) what happened in the note is what happened and everything that's not documented somewhere is a different story