Oct 2006 Table of Contents

LETTERS

Documenting away a malpractice suit



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Fam Pract Manag. 2006 Oct;13(9):16.

Dr. Edward Zurad did a fine job of describing how to protect oneself from malpractice claims in his article “Don’t Be a Target for a Malpractice Suit” [June 2006]. I enjoyed reading it.

As a medical director for a large insurance company, I read more progress notes and letters from physicians about medical necessity than most practicing physicians will see in a lifetime. I am dumbfounded at the lack of documentation and the attorney-esque hyperbole that I see every day. Vital signs are more often omitted from the physical exam than recorded; right versus left is commonly omitted when discussing bilateral body parts; medical history is usually garbled; medications are not noted; and so it goes. It’s downright embarrassing sometimes.

So, expanding somewhat on Dr. Zurad’s points, these are my hints for avoiding malpractice risk:

  1. Include the full date (month/day/year) and the time of the encounter on every note.

  2. Initial every lab report (and again, include the full date and time).

  3. Read and countersign nurses’ notes.

  4. Include the indication for the medication when writing a prescription (e.g., “for high blood pressure”).

  5. Write notes that are clear, even redundant if necessary, to prevent misunderstandings.

  6. Document all phone calls, noting the time, date, phone number, name of other party, nature of the conversation and resolution.

  7. Always ask female patients “Are you pregnant?” and record the response for every encounter, even if you think you know the patient is not pregnant. This will help to ensure that treatments, medications and tests that are better avoided during pregnancy aren’t prescribed without careful consideration of the risks and benefits.

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