Page 31 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

medical record could have made this case appear quite differently

to an outside observer.

Documenting After an Adverse Outcome

Even the strongest physician-patient relationship faces a challenge

in the event of an adverse outcome. If such occurs, first and

foremost, the physician should attend to the patient’s medical
needs. Once this has been addressed, it is imperative that the

matter be investigated promptly and openly. Before divulging any

information about the incident to the patient or family, the

physician should verify that all of the facts are correct and

complete. A frank discussion with the patient and family should
include a description of the events, without either accepting or

placing blame, along with a sincere acknowledgment of regret for

the unfortunate nature of the event. It is important to control the

situation by providing only factual information and not speculating

on what could have happened or what might have caused the
adverse outcome. Avoid responding with defensiveness or finger-

pointing, which only adds fuel to the fire. As soon as possible after

the event, the medical response should be factually recorded in

the medical record. Plans for further follow-up care, if indicated,

should also be documented.

Careful documentation of the most accurate accounting of the

events is crucial. Avoid emotional comments, speculation and

blame. Words such as “inadvertent,” “accident,” “mistake,” and

“error” can have multiple meanings and could undermine the

defensibility of the chart while adding no useful information. Many

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