CaMD

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Do any of you have a good resource for learning how to write forensically sound H&P/progress/consult notes? aka a readable book or a good website that makes it clear what to definitely document/say vs not in an effort not to get sued?

I 've heard that both 'less is more' don't say more than you legally have to, and also 'more is more' document every tiny detail.

Thanks in advance.
 

whopper

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The bottom line is, how will it look to a judge and jury?

Some very general guidelines...
1) Notes should be legible. Several doctors cannot read even their own handwriting. If you are sued, you'll have a heck of a time piecing together a case from several months ago when you can't even read what you wrote.

2) The notes should satisfy the legal principles involved. E.g. If you are being sued for malpractice, the documentation needs to show that you did not commit malpractice.

Writing on this specific issue, you need to know what can legally be at stake. E.g. if you are recommending a medication, you need to document that you discussed the risks and benefits of a medication since the legal standard is doctors are supposed to give the patient at least a reasonable amount of information for them to decide if they want it or not (the reasonable patient standard).

Some of the issues that can come up 1) standard of care 2) benefit/risk ratio 3) termination of patient care which can lead to an accusation of abandonment 4) privacy: this can be trumped if the patient said they intend to harm others

So, for example, on a consult for an agitated demented patient, where you recommend an atypical antipsychotic, you should document why you are recommending the antipsychotic despite the blackbox warning. E.g someone could write "The risk of administering an atypical antipsychotic to this patient who frequently attacks staff is immediate and more likely in the future in my reasonably medical opinion than not giving an antipsychotic, and it falls within the standard of care.

You should write the note in a manner where another doctor, but better, a judge and jury can understand (with the explanation of a doctor on what specific terms mean) what you did and find it reasonable. You don't have to write in a manner where layman could understand everything.
 

CaMD

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Thanks, Whopper. What brought this to mind is that I just finished reading The Practical Art of Suicide Assessment by Shea (which I bought bc it was recommended on this forum, and it is great!) and he has a section on documentation of a suicide assessment and it had some specific tips, like never write that a patient is "suicidal" in the "objective" part of your note, because that's actually an opinion and it looks bad if anything happens later, so only write "suicidal ideation" and discuss the risk of suicide in your assessment. Made me realize I have never looked at my notes through the eyes of a lawyer before.