resources on how to write notes to reduce liability risk?

[tsbqb]

Hi everyone, I am a new attending and I was hoping someone could point me towards some resources that can teach me how to write good notes that can be defended in the event of a suit?

Furthermore does anyone have any hard and fast rules that do reduce your liability risk in regards to documentation?

I am pretty clueless on the topic. Im not sure what to say or not say, if I should list differentials, what to do if a patient refuses a procedure (ie refusing an LP in s suspected meningitis case) etc.

Any help is appreciated!

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[TooMuchResearch]

What did you do in residency?

 

[southerndoc]

I've mentioned various ways in a bunch of threads. Perhaps it's time I compose everything and start a new thread.

 

[southerndoc]

I've mentioned various ways in a bunch of threads. Perhaps it's time I compose everything and start a new thread.

Give me a few days and I'll get something up. Been busy with EMS and hedge fund stuff. Should be a good use of Dragon.

EDIT: Do we have a way to write-protect this stuff to limit dissemination? I don't want to write something on here and have a plaintiff attorney find it and ask a doc on the stand "Dr. X, did you write that in the chart because you read it on a web discussion forum that it would limit your liability?"

(Trust me, plaintiff attorneys will do that. I reviewed a deposition recently where the plaintiff attorney asked the doc 40+ pages worth of questions related to the onset of symptoms because he had simply checked "3-5 days" and didn't further document when each symptom occurred).

Plaintiffs are sharks, and they will do everything they can to get their prey. Don't ever forget that. Things that you would think are never possible to go after will surprise you. Nothing is off-limits.

 

[BAM!]

Give me a few days and I'll get something up. Been busy with EMS and hedge fund stuff. Should be a good use of Dragon.

EDIT: Do we have a way to write-protect this stuff to limit dissemination? I don't want to write something on here and have a plaintiff attorney find it and ask a doc on the stand "Dr. X, did you write that in the chart because you read it on a web discussion forum that it would limit your liability?"

(Trust me, plaintiff attorneys will do that. I reviewed a deposition recently where the plaintiff attorney asked the doc 40+ pages worth of questions related to the onset of symptoms because he had simply checked "3-5 days" and didn't further document when each symptom occurred).

Plaintiffs are sharks, and they will do everything they can to get their prey. Don't ever forget that. Things that you would think are never possible to go after will surprise you. Nothing is off-limits.

can you discredit a plaintiff's expert witness by asking them on the stand how much they are getting paid to be a witness? Same thing for Plaintiff Attorney?

 

[BoardingDoc]

can you discredit a plaintiff's expert witness by asking them on the stand how much they are getting paid to be a witness? Same thing for Plaintiff Attorney?

This works both ways.

 

[gutonc]

EDIT: Do we have a way to write-protect this stuff to limit dissemination? I don't want to write something on here and have a plaintiff attorney find it and ask a doc on the stand "Dr. X, did you write that in the chart because you read it on a web discussion forum that it would limit your liability?"

The only thing we could do we be to post it in a semi-closed forum like Practicing Physicians. If you post anything here in EM (or any of the open forums), the Googlez will have them within a day and they'll forever be in the wild.

 

[tsbqb]

I've mentioned various ways in a bunch of threads. Perhaps it's time I compose everything and start a new thread.

That would be awesome!

 

[plick]

Hey all, new attending here as well. Does anyone know if Med mal cases are open to the public? I'm thinking of finding a case in a nearby court and observing. If allowed, I think this will be very helpful


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[southerndoc]

Hey all, new attending here as well. Does anyone know if Med mal cases are open to the public? I'm thinking of finding a case in a nearby court and observing. If allowed, I think this will be very helpful


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In general, yes.

 

[migm]

your residency didn't include instruction on how to assess capacity? to discuss risks and benefits with a patient who has refused a procedure, test or admission?

 

[Angry Birds]

your residency didn't include instruction on how to assess capacity? to discuss risks and benefits with a patient who has refused a procedure, test or admission?

I don't get the need for all these snarky comments... We all come out of residency with some holes that need to be plugged. Plus, we can always improve after residency and learn new tips from people from other programs.

I really think if you can't answer the question, then just move on. No need for the snark.

 

[Tenk]

I don't get the need for all these snarky comments... We all come out of residency with some holes that need to be plugged. Plus, we can always improve after residency and learn new tips from people from other programs.

I really think if you can't answer the question, then just move on. No need for the snark.

I don't think it's so much snark as bewilderment because in today's current malpractice environment it's a hot topic in residency. Hell, half of my residency training was about how to not get sued!

 

[migm]

there was zero snark. i am truly surprised.

 

[Angry Birds]

there was zero snark. i am truly surprised.

Roger that! Fair enough!

 

[tsbqb]

your residency didn't include instruction on how to assess capacity? to discuss risks and benefits with a patient who has refused a procedure, test or admission?

yes i learned that. but that means my notes are perfect? every attending that did an EM residency writes notes of equal quality? Every year at ACEP there are multiple lectures on how to improve your documentation to reduce risk. if everyone writes such great notes why do those lectures happen? why did the book "bouncebacks" get written?

clearly there are ways to improve. in any event if anyone can offer any resources id appreciate it.

 

[deleted109597]

yes i learned that. but that means my notes are perfect? every attending that did an EM residency writes notes of equal quality? Every year at ACEP there are multiple lectures on how to improve your documentation to reduce risk. if everyone writes such great notes why do those lectures happen? why did the book "bouncebacks" get written?

clearly there are ways to improve. in any event if anyone can offer any resources id appreciate it.

Other than the ones you've already named, and the high risk lectures they offer, that's pretty much it.

 

[Birdstrike]

Hi everyone, I am a new attending and I was hoping someone could point me towards some resources that can teach me how to write good notes that can be defended in the event of a suit?

Furthermore does anyone have any hard and fast rules that do reduce your liability risk in regards to documentation?

I am pretty clueless on the topic. Im not sure what to say or not say, if I should list differentials, what to do if a patient refuses a procedure (ie refusing an LP in s suspected meningitis case) etc.

Any help is appreciated!

There's really only one way to meaningfully reduce you liability: Don't be a doctor. Then wait three years.

Until you're ready to do that, just be a good doctor and leave ample evidence of it in the EMR.

The rest you hear on the subject is bullcrap.


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