Page 30 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

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 physicians assume that “inadvertent” is synonymous with
“unintentional”. In fact, some dictionaries define it as “heedless”,

“careless”, or “negligent”—words you certainly wouldn’t want
used to describe your care. It is best to stick to a simple,

objective description of what happened and let the facts speak
for themselves.

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