Page 42 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

ketones’ and to go home and restrict his intake of carbohydrates

and to double his medications. He will require admission to ICU
for DKA.”

Usually, jousting centers around comments on prior care, either

to a patient directly or in the medical record; for example, “You
mean Dr. Jones didn’t order a CT when you saw him with these

symptoms?” Patients often have questions about another
provider’s care, particularly when the condition changes course

and/or additional symptoms or testing reveals a different
diagnosis or treatment plan is indicated. When patients are

questioning you about the care provided by another, it’s
recommended that you refer the patient back to the original

care provider for clarification. It would be unfair to assess
another provider’s judgment at the time and under different

circumstances. Jousting in the medical record, particularly
if directed at a particular provider, is a gift to a plaintiff’s

attorney. This type of note creates an ideal setup for a plaintiff’s
attorney and may even be the sole factor in filing a lawsuit; for

example, “Dr. Smith continues to overprescribe opioids without
addressing the cause of Ms. Johnson’s pain. After discussing the

risks of continuing this dosage with Ms. Johnson, she desires to
continue the medication despite known risks.” Once negative

comments pertaining to prior care make their way into the
medical record, the defensibility of any claim regarding the care

is more of a challenge.

If that note ends up in litigation, it can become evidence, and

the author may also be dragged into the case, to be used as
a quasi-expert to criticize the prescribing physician. This type

of documentation among professionals often harms both
reputation and relationships. If you have a concern about

another provider’s care, rather than commenting to the patient

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