Page 23 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

“clearly stoned”, “drunk”, or “uneducated”. Unflattering patient

descriptions often do not add anything substantive or helpful
to the care provided and almost always anger a jury. While you

might think this should go without saying, all of these patient
descriptors have been identified in SVMIC cases.

For example, documenting that the patient is a “malingerer”

does not give any description of the presentation, symptoms, or
other differential diagnoses you may have considered. This will

likely appear judgmental and dismissive to a jury, particularly if
there was a missed or delayed diagnosis. Rather than entering

potentially offensive labels into the chart, you should instead
chart the objective observations underlying the conclusion:

“Patient complains that she has episodes of 2-3 minutes of
shortness of breath and ‘queasy’ stomach pain. GI, pulmonary,

and cardiology workups have all been negative. I am unable to
determine an objective explanation for her episodes.”

Inappropriate humor can also be used to portray the physician
in an unfavorable light. In one chart review, the following

entry was discussed: “Ms. Jones presents today with more
complaints than a dog has fleas.” It was pointed out to the

provider that, should one of those fleas decide to bite Ms.
Jones, such documentation could be used to depict the care as

careless and indifferent. Avoid the temptation to label the patient
or give a head’s up to subsequent physicians by including

acronyms such as “SOPCAL” for same old problem – crazy as a
loon, “PCL” for “pre-code looking”, “GOMER” for Get Out of My

ER!, “PBS” for “pretty bad shape”, and others not appropriate to
include in this course. You do not want to be explaining such

acronyms in a deposition or in front of a jury as it certainly will

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