Risk Manager
Documentation Essentials
Following this specific advice on recording key interactions will help protect you from malpractice lawsuits.
Coordinated By Jeffrey D. Weinstock, ESQ.

A patient calls your office complaining about the sudden onset of floaters and is told to come in immediately. The patient shows up a week later with a completely detached retina and no vision in the eye. If you can't document that an immediate appointment was offered, you could face a lawsuit.

Leaving out information -- or having inaccurate information because of poor documentation -- is an invitation to malpractice litigation.

In this article, I'll explain when and how to document your doctor/patient and doctor/doctor interactions to protect yourself and your practice.

Documentation must be accurate, timely, complete and clear. A busy day is no reason for leaving out information.

	Photography: Pat Simione; Digital Imagery: John Bruszewski

COMPLETENESS COUNTS

• Appointments. When a patient calls for an appointment, note the time of the call, the name of the person who answered the phone, and the information that was exchanged. For example:
  "Jan. 22, 2001, 10 a.m: Mrs. X told Mary that she experienced some vision loss an hour ago. She was told to come in immediately, but patient refused -- had hair appointment. She will come in 1/25/01 to see Dr. Y."

• Messages. When you or a staff member takes a message, during office hours or in the middle of the night, document the call, the date, the time, the reason for the call and the recommendation. If you take a call when you're out of the office, deliver the message to the office in a timely manner. Do the same for consultations.

• Office visits. When you see a patient in the office, take an adequate history. Document any questions asked by the patient and how you answered them.
  Document exams with a diagnosis, treatment plan and the date when the patient should return. This must be done on every visit, not only for self-protection, but to facilitate correct reimbursement. The record must be legible. If you dictate, make sure to review every notation in the chart.

• Tests. Clearly note the tests you've ordered and the reasons for them. Have an office system in place that will track the tests -- from the time they're ordered until the results are communicated to the patient.

• Referrals. When you see patients on a referral or consultation, communicate with the referring physician by letter. With consultations, see the patient as soon as possible and have a system for follow up. In emergency cases, phone the referring physician, noting the gist of the conversation and time in your chart. Later, note what medications you ordered and what transpired during the patient's treatment.
  If you refer a patient, document the physician to whom the patient is being referred, the date and time of the referral, the reason for the referral, and when the patient will be seen.

BE CLEAR WITH COLLEAGUES

Documentation must be easy to understand. Anyone in your office should be able to look at the chart and understand what's happening with the patient without having to call you. The same applies to consultations and hospital patients. Mark the date and time on hospital charts. Answer and note any questions raised by other physicians or nurses. In fact, you should initial all notations on all your patients' records to indicate that you've read them.

As part of your compliance program, review office records on a regular basis for completeness, accuracy, legibility and correctness of billing.

Ignoring these rules invites trouble. Although medical school training focuses on patient diagnosis and care, it's up to you to deal with the realities of life in respect to the details of charts.

Frank J. Weinstock, M.D., FACS, is professor of ophthalmology at Northeast Ohio Universities College of Medicine in Canton, Ohio, and is also in private practice with Canton Ophthalmology Associates, Inc. in Canton.