Careful documentation can mean the difference between a guilty verdict in a medical malpractice case and the case being thrown out. It’s worth the trouble to ensure you do it right.
1. Document your thought process. Your note should indicate how you arrived at a differential diagnosis. In the absence of contrary evidence, juries will assume the worst. For example, if your patient has chest pain and your diagnosis is gastroesophageal reflux disease (GERD), your note should explain why acute coronary syndrome is less likely and that you discussed this with the patient.
2. Document shared decision making. Notes that convey physician-centered decision making may offer less protection in a lawsuit. Shared decision making involves explaining options, risks, and benefits, and agreeing on a plan. Be sure to document your discussion and agreed plan.
3. Document expectations. Using orienting statements, such as explaining what will likely happen next in a patient’s care, can reduce risk. Document any warnings given or risks discussed. A useful phrase in communication and documentation is "recheck if not better."
Adapted from "How to Reduce Your Malpractice Risk."
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