Page 41 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

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 in spite of 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 or documenting

personal opinions in the medical record, contact the provider for

clarification. Be sure you don’t “defend” yourself in the medical
record as this often simply benefits plaintiff’s attorneys and drives

up settlements and/or verdicts. Consider the following case:

Page | 41