Ironclad Documentation - How do you CYA?

[treasurefull2]

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I was wondering what type of specific things people write in the chart to cover their butt from being blamed in case of a complication or what you wish you may have written when something had gone wrong.

I have one attending who always writes "eyes taped during transport to ICU". I have another attending who documents repeatedly during surgery "eyes and pressure points checked" every 15minutes.

In another interesting story, an attending of mine was indicted for providing the anesthesia for a case where a patient required dialysis (or may have even died, I can't remember) following kidney donation. The patient was a very poor candidate and had no business donating any of his kidneys. My attending had a long discussion with the patient preoperatively telling him he doesn't think he is a great candidate for the surgery, more importantly he wrote a long note in a chart to this effect, when the lawyers came around he got indicted, but he was dropped from the case because of his documentation..

Is there anything that you write whether in the preop, intraop, postop or any other time that you think is important or saved your butt???

Share your thoughts...

 

[Idiopathic]

if no felony was alleged, there is no 'indictment', so you may choose to rephrase that

outside of that point, its fair to say that you cant document everything, and documentation doesnt protect you from something happening...you can check eyes every 15 minutes and someone can still wake up blind or with corneal damage, and you are not excluded from liability simply because its in your chart that you "checked" them.

i think its a good idea to have a plan, document discussions with family, surgeon and in room provider, detail deviations from the plan (difficult airway, hypotension necessitating treatment, etc.) and ultimate disposition (patient resting comfortably in PACU, patient transported to ICU). outside of that, more words doesnt necessarily protect you

 

[treasurefull2]

Thanks, perhaps indicted wasn't the right term, but a lawsuit was initiated and he was one of the defendents initially.

Nonetheless, I agree, I don't think any documentation, no matter how extensive, is a gaurantee against being found liable. However, good documentation can and will support the decisions you make and will protect you if there are any doubts later on.

Anyway, I was more interested in specific things people write in the chart...

 

[deleted126335]

even when you write alot, it can be picked apart or portrayed as self serving. You can't underestimate the ability of lawyers to spin.

 

[bostonblaz]

I write as little as possible on the anesthesia record. Anything you do ends up projected on a wall and some douchey lawyer will ask you every possible question about it and the halftards that sit in the jury believe that if you can't answer each of them you lied or did something wrong. On that record should only be what you have given and what you have done. If you preform an intervention that isn't a common action your thought process should be explained. Blaz

 

[seinfeld]

I write as little as possible on the anesthesia record. Anything you do ends up projected on a wall and some douchey lawyer will ask you every possible question about it and the halftards that sit in the jury believe that if you can't answer each of them you lied or did something wrong. On that record should only be what you have given and what you have done. If you preform an intervention that isn't a common action your thought process should be explained. Blaz

I second the above. I only write when something is out of the ordinary happens or an obvious complication occurs and how I managed it

If you write the same thing for every case then what's the point of writing it? My favorite BS statement is " smooth IV induction" until I see someone write " horrible IV induction" I don't believe it has any meaning. When the IV infiltrate during induction I make a note that it happened.

 

[pgg]

Judging from the cases I take over sometimes, the #1 defensive charting technique out there is to document the vital signs you'd like instead of what comes up on the monitor.

Funny how SBPs less than 75 and HRs over 120 never make it onto paper. 🙂


When I was a resident a couple of malpractice and hospital attorneys made a presentation to us in lieu of grand rounds one week. The thing they emphasized the most was to have a complete and legible chart. Incomplete charts let the plaintiff's attorneys make up whatever they want to fill the gaps. Sloppy charts tell juries you're a sloppy doctor.

 

[Planktonmd]

Only document the absolute minimum necessary.
If you think that writing essays in the medical record is elegant and has a legal value you are WRONG.

 

[Ignatius J]

I think the best 'CYA' medicine is being empathetic and nice to the patient. All studies show that bad doctors with good bedside manner get sued less than good doctors with poor bedside manner. I'm not saying to be a bad doctor, but that a patient suing you (and it can be for anything) simply comes down to whether or not they like you many times.

 

[Arch Guillotti]

Only document the absolute minimum necessary.
If you think that writing essays in the medical record is elegant and has a legal value you are WRONG.

I don't document all that much either.

Exceptions are things like unanticipated difficult airway (mostly for the next guy), unexpected intraop complication, discussion with very high risk patient, etc.

Most of the time I just let the nurses chart their stuff and I just sign it.

 

[Idiopathic]

I think the best 'CYA' medicine is being empathetic and nice to the patient. All studies show that bad doctors with good bedside manner get sued less than good doctors with poor bedside manner. I'm not saying to be a bad doctor, but that a patient suing you (and it can be for anything) simply comes down to whether or not they even remember you many times.

edited