Chart mistakes that can burn you

March 1, 2008

Some words that sound innocent can zap you. Recognize-and steer clear of-these charting errors.

It's a "gotcha" moment you'll never want to experience. While the jury in a malpractice trial looks on, the plaintiff's attorney projects these words from the medical record on a giant screen: "Mr. Jones lost a little blood." Then the attorney turns to the defendant on the witness stand. "In fact, Mr. Jones lost 4 units of blood during surgery. Can you explain why you minimized what happened in your note?"

Many a doctor sued for malpractice has been snared by what he wrote, or failed to write. The gamut of goofs is wide, says San Francisco GP and JD Dan Tennenhouse, co-author of Risk Prevention Skills for Physicians. Self-serving understatements like the one above, ambiguous words turned to the plaintiff's advantage, and omissions of warnings to patients and explanations of medical logic are among the most common mistakes.

In lectures at medical schools and hospitals, Tennenhouse drills doctors on documentation that's clear, precise, and thorough. Compose your charts this way, he says, and you'll deprive a plaintiff's attorney of a damning screen shot to use against you. You may even avert a suit. Here's how.

Choosing the right words is always important, but it's especially crucial in documenting patient care. Imprecise or incorrect language can make it seem that the doctor is shading the truth to protect himself, or can smack of poor clinical judgment. Plaintiffs' attorneys comb through patient records to find such linguistic missteps, says Tennenhouse, citing examples of what to avoid:

Understatement. Describing a semi-comatose patient as "drowsy" or noting that a patient who's doubled over in agony "complains of a little pain" is an inaccurate characterization, just as "a little blood" is an inadequate description of 4 units of blood. Never underestimate the danger of understatement, Tennenhouse says.

Exaggeration. Overstatement also gives a plaintiff's attorney an opportunity to undermine your credibility. "Let's say you jotted down, 'Every possible precaution was taken,'" says Tennenhouse. "If an attorney can prove there was one precaution you missed, your statement turns into a lie and the jury starts believing the plaintiff's story."

Noncommittal or vague words. "It's better to write, 'Patient says he ingested a bottle of aspirin' than 'Patient allegedly ingested a bottle of aspirin,' " says Tennenhouse. "You may think you're playing it safe, but 'allegedly' sounds like a defensive measure. It means, 'This is what I heard, but I don't know if I believe it.'"

In general, vague words are subject to hostile interpretation. Suppose, after evaluating a patient with congestive heart failure who presents with a headache, you tell her the headache isn't alarming but that she should notify you if it worsens. In the chart you note, "Patient was reassured about headache."

The headache indeed intensifies, but the patient never reports it. Then she suffers a stroke, which leads to a lawsuit. At the trial, her lawyer projects the word "reassured" on that giant screen. "The defendant," he says, "told Mrs. Jones she could ignore her headache-it wasn't serious."

"That's a common interpretation of the word 'reassure,'" Tennenhouse warns. "The trouble is, it misrepresents what you said."