Page 22 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 “Skin is hot to touch.”

 “Crackles were heard upon auscultation of the lower

lungs.”

 “There was a smell of melena when I entered the room.”

Refrain from documenting derogatory, discriminatory or other

callous comments that could be viewed as disrespectful or

prejudicial by a jury such as “stubborn”, “crock”, “loser”, “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.

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. 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

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