Legal and regulatory proceedings
Put it in writing, with care
An article for physicians by physicians
Originally published October 2001 / Revised August 2008
Documentation in clinical notes and in reports to third parties should be factual, objective, and appropriate to the purpose.
Of interest to physicians dealing directly with patients
How you record your observations can help keep you out of medico-legal trouble.
Consider these scenarios:
A family physician had a middle-aged patient for many years, a nurse who became unable to work with what is generally called "burnout". One problem was her relationship with her manager, about which the patient confided extensively. A sick note provided by the physician documented stress "due to ongoing problems at work and harassment by (the manager's name)." The patient gave this note to her employer, and the manager complained to the provincial regulatory authority (College).
The complaints committee was critical of the physician. Their decision reads in part, "…the problems would not have arisen had the doctor used language such as 'the patient perceives' or 'the patient complains of ' or 'the patient states.' The doctor made statements based solely on information given by the patient, without attributing that information source."
Disability claims and the associated examinations are a frequent source of complaints. The patient may have expressed frustration with the procedure used by a third party (usually an insurance company) to process the claim and may see the physician as a solution. The patient may become even more frustrated if the physician's letter does not provide sufficient information or is simply not supportive.
Physicians are advised to seek clarification of the third party's needs. Claims assessors need factual information about the patient's condition to determine whether that condition is covered by that employer's policy. The employer may simply need to know whether the patient is fit or unfit for work, or if the employee's illness requires that the work be modified. Patients should provide written authorization. Physicians should strive to be objective when stating their medical opinions.
- Physicians are particularly vulnerable in divorce and custody issues. In most cases information has been provided by the patient or parent; physicians should be careful in their documentation to acknowledge the source of the information. It is particularly important to limit any opinion to your area of medical expertise, especially when discussing parenting capability.
In any scenario, after you have written a note, look at it and ask yourself:
- Is this true and is it my own first-hand knowledge of events?
- Can I vouch under oath that this is true?
Then, look at the note again, and ask yourself:
- Is this objective?