Duties and responsibilities
Anatomy of a well-written note
An article for physicians by physicians
Originally published March 2005 / Revised May 2008
Avoid medico-legal difficulties by writing factual and objective notes.
Of interest to all physicians
Physicians are often asked to write notes for various reasons—from the simple need to allow an ill person to miss jury duty, to the complex need to settle litigation. In the scope of medical practice, writing a note seems like a straightforward task; however, if done carelessly, it can lead to a variety of medico-legal problems including a complaint to a regulatory authority (College) or litigation against the physician.
Who might have reason to complain about a physician's note? Anyone who feels they have been adversely affected by the note including spouses, employers, and insurance companies. What can the complaint be based on? Typical allegations are lack of objectivity, unsupported statements, or conclusions that aren't medically sound.
Here are two cases that illustrate what can happen if a note is not written with care.
A physician received a visit from a patient's wife. The physician had previously spoken to the patient in the wife's presence. In this visit, the wife reported that the patient was refusing treatment for his psychiatric condition. The wife asked the physician for a note stating the patient's condition, leading the physician to believe she would be seeking the necessary help for the patient. A short time later the wife filed for divorce using the physician's note to secure the divorce and custody of the couple's children.
The patient complained to the College about breach of confidentiality and launched a legal action. Although the patient had not objected to having his wife present when speaking to the doctor, the College was critical of the physician for giving the wife information without the patient's knowledge and consent. The legal action was settled and a payment was made by CMPA on the member physician's behalf.
During a course of treatment, a patient admitted to her physician that she physically assaulted her husband when under stress and she requested medication to prevent the assaults. The physician considered the patient's small size when compared to her husband's and gathered more information from the patient. The patient later told the doctor she would be seeking a separation from her husband and requested a supportive letter. The physician provided a letter addressed "To Whom It May Concern" in which she indicated her beliefs about the patient's condition and marriage relationship, which were based entirely on the patient's statements. The patient introduced the physician's reports and letter into divorce proceedings.
The husband complained to the College, and after a thorough investigation the College issued the following criticisms of the physician's letter:
- It failed to clarify that some of the information was based solely on subjective history provided by the patient.
- It drew conclusions that were best left to the courts and/or police when it commented on the physician's views about the likelihood of the ability of someone to assault another person when the alleged assailant was at a gross physical disadvantage.
- It contained an unprofessional comment about the husband's mental state. Physicians are expected to perform an assessment of an individual including a thorough history and a mental status examination before assigning personality traits or making diagnoses.
- As a medico-legal document, the letter should not have indicated the physician's personal beliefs about marriage and divorce.
The husband also brought a legal action alleging defamation. The matter was concluded on the basis of a formal written apology from the doctor.
The bottom line
The following are risk management considerations about notes:
- Do your notes consider your patient's need for confidentiality?
- Do you have proper authorization from your patient prior to providing personal information?
- Is the note factual and objective? You will be judged on the facts and your actions, no matter how good your intentions. Don't allow your emotional attachment to a patient or belief in a patient's best interests to overrule your obligation to provide factual and medically-sound information.
- Does your note differentiate direct knowledge from second-hand information?
- Have you been cautious about drawing conclusions based on incomplete information?