Page 26 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

But years later, at the point when a malpractice claim would

typically be judged, the context has changed significantly.
“When your documentation gets into a lawsuit, the relationship

is flipped, right? Everybody’s trying to read your documentation
to recreate the context,” he said. “Craft your documentation in

such a way that many years down the road, somebody can read
it and understand what the context was; that’s a little different

than just writing during a busy day to try to communicate
whatever you need for billing or for communication of care.”

If that sounds difficult to do, don’t worry. Dr. Smith broke down

his big-picture documentation advice into 10 actionable tips.

1 Minimize cut and paste

Overuse of cut and paste carries multiple risks. First, if you
move your own words from one day to another without

careful editing, the information may be inaccurate. “You
render a note which becomes invalid and indefensible.

You might have seen a note like this, where someone says
in error that [a patient was] intubated and extubated and

intubated and extubated all in the same day,” said Dr. Smith.
There are also risks to reusing others’ words. “If you cut

and paste somebody else’s words like a radiology report,
those words become your own. You have to justify those

findings yourself as if they’re your own, and then you also
have to justify why you chose to cut and paste that aspect

of information, as opposed to something else in the vast
expanse of [a patient’s] medical chart,” he said.

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