Legal and regulatory proceedings

Navigating legal or regulatory processes

A case for keeping good notes

An article for physicians by physicians
Originally published September 2005 / Revised May 2008
IL0530-2-E

Abstract

Poor charting may be perceived as reflecting less attention to detail and risks the conclusion the care provided was poor.

Of interest to all physicians

This case illustrates how records are used to evaluate a doctor's care.

A regulatory authority (College) received a complaint from a young man about an emergency department visit he made the day after he had a knee arthroscopy. He had presented in emergency complaining of right calf pain and asked specifically about deep vein thrombosis (DVT). The man said the emergency physician told him it was highly unlikely a blood clot would present so soon after surgery.

The records made by the emergency physician were restricted to the following: "pain post-arthro x 24 hours, swelling, no infection, motion, tenderness v, effusion +." The diagnosis was post-arthroscopy pain. The rest of the notes record treatment with analgesics. The nurse had not taken any vital signs and had noted slight swelling of the knee.

Five days later, the young man, still in pain, visited another doctor. The second doctor made a clinical diagnosis of DVT, which was later confirmed.

In his complaint to the College, the young man said he was concerned he had been unprotected against pulmonary embolism and sudden death for the five days between physician visits. His belief that the first doctor should have diagnosed the DVT was supported in his mind as the second doctor had "rolled his eyes and shook his head from side to side" when he learned of the initial diagnosis.

When responding to the complaint, the emergency doctor was able to supplement the information appearing in the record with several recollections. The patient had claimed the whole leg was swollen down to the ankle, while the doctor was able to say there was a large right knee joint effusion with no swelling and no tenderness in the calf. There were no temperature changes or skin changes.

Lack of documentation a concern

In its conclusions, the College complaints committee wrote: "There is no documentation that the calf was measured and compared with the left calf. There is no evidence that Homans' sign was elicited. The patient had presented with a specific complaint of right calf pain and had asked about deep vein thrombosis. The committee can understand why the doctor ascribed the symptoms to the recent arthroscopy. DVT is rarely as painful as described by the patient, and even with a light tensor bandage one should not develop a DVT so quickly. The committee would like to be clear that it is not concerned with the doctor's diagnosis of ‘post-arthroscopy pain'; given that his clinical observations are supportive of this diagnosis, it was not an unreasonable conclusion to reach despite later being proven wrong. Rather, the committee is concerned by lack of documentation in the record of the analytic process the doctor used to arrive at the conclusion."

The doctor was counselled about the records.

The bottom line

In this case, the College held that the physician's records were insufficient to support his position that the care had been appropriate. The main purpose of the medical record is to provide the doctor and other members of the health care team with a record of information and medical reasoning. This facilitates the planning of investigations and treatment of the patient.

Poor charting may be perceived as reflecting less attention to detail and risks the conclusion that care was poor. Good records help demonstrate good work.

Documenting the patient encounter

If it is necessary to change an entry while writing your note, cross out the entry with a single line and initial the change. After an adverse outcome, an addendum, clearly labelled as such, dated and signed may be added to clarify the care given previously if you feel the record is inadequate or to assist others in the further care of the patient. The addendum should be factual.

Resist the temptation: Tampering with the medical record after learning of a legal action, threat of a legal action or other patient complaint may be seen as unprofessional and dishonest, and will likely damage your credibility and defense.

  • Do NOT later change an existing entry.
  • Do NOT black-out or white-out words or areas.
  • Do NOT insert entries between lines or along the margins of the chart as these may appear to have been added later, casting doubt on their reliability.
  • Do NOT add an addendum to the chart after learning of a legal action, threat of a legal action or other patient complaint.

 


DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.