Documenting away a malpractice suit


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.


Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.


Copyright © 2006 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Nov-Dec 2021

Access the latest issue
of FPM journal

Read the Issue

FPM E-Newsletter

Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights."

Sign Up Now