Page 31 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

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

9 Consider deferring some decisions to the patient

Even better than explaining and documenting tough

decisions is letting the patient and/or family make them,
when they are capable and sufficiently informed. “For a

plaintiff’s attorney to look at a medical record and see that
the decision to proceed, after a full explanation of risk and

benefits … was actually made by the patient … it puts you in
a very good stead,” said Dr. Smith.

10 Do not alter the medical record after the fact

This final tip is actually “non-documentation guidance,” Dr.
Smith noted, and it applies when you’ve been notified of a

malpractice claim.

In such situations, many physicians feel the urge to go
review the chart, he explained. “And if that urge slips too far,

you might actually get the urge to go back and alter notes.
Altering notes will not help you. In fact, altering notes after

the fact is probably the quickest way to ruin your credibility
as a witness.”

All of the widely-used EHRs track and timestamp
documentation changes, and a physician having made

changes after being sued can be used to dramatic effect
by a plaintiff’s attorney at trial, according to Dr. Smith. “It’s

absolutely indefensible, and there’s nothing that an expert
witness can do to help you.” After notice of a lawsuit, “seek

whatever support you need. Talk to risk [management], talk
to your local legal representation, but don’t touch the chart,”

he said.

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