■ Physician-patient:

Communicating effectively with patients to optimize their care

Documentation - a lawyer's story

Type of activity: Video

Activity summary

The short video "Documentation – a lawyer's story" presents an experienced lawyer recalling a real-life example that highlights the importance of documentation in reducing medico-legal risk. The facilitation questions and suggestions to faculty focus on helping learners to understand the importance of good documentation both in the provision of safe patient care and reducing medico-legal risk.

Transcript

Setting: A lawyer, Ms. Donna MacKenzie, speaks to the camera about a real-life example of good documentation.

Voice over: Ms. Donna MacKenzie has assisted many CMPA members. Here she describes an important lesson related to documentation of good care.

Donna MacKenzie, Partner — Gowling WLG: First of all, what we deal with most often, and what most physicians probably think we deal with most often, is their actual care provided to the patient. But what we also see are cases where there are allegations that the plan for care or the transfer of care to other healthcare providers was negligent.

I distinctly remember a case, it's a number of years ago but it stays in my mind because the physician's note was very detailed, most detailed I'd seen. And I remember saying to the physician when I met him, "if all notes were like this, you'd put me out of business". And he laughed and said, "well don't worry, this was a particularly detailed note because I was going on holidays. I knew that I had to transfer the information. I wanted it written down."

Anyways it was interesting because he had charted his key observations about the patient, had charted what his plan of care was in a detailed manner, and had charted the tests that he thought had to be undertaken in accordance with that plan of care.

Took his chart notes from him, copied them, sent them over to plaintiff's counsel, talked to plaintiff's counsel a couple of days later. Plaintiff's counsel said, "hmm, I'm going to leave your doctor in the action, but I can tell you I am not going to be focusing on him. My focus just shifted to some of the other defendants."

The good news story for that physician: he got out of the action very early because his chart note was so clear plaintiff's counsel knew what he'd say in discovery. Not so good for the other doctors because the evidence was that that information that our physician had charted had been verbally transferred. And unfortunately the other physicians weren't as diligent in their follow-through on the plan of care as we would have liked them to have been. But, for that fellow who did the good chart note, that saved him.

Take the time to communicate. And it never hurts to communicate twice: eye-to-eye to the person that you are transferring over to, or ear-to-ear if you are on the phone. But then back it up with a detailed chart note, because it's what you think about the case at the time; it's what you've communicated at the time. And for that busy professional who you're talking to, eye-to-eye or ear-to-ear, and they're half distracted by their other fifteen cases, they can then go back to your detailed chart note and say, "ah ha, yes, good a, b, c ... done."

Concluding facilitation questions: How does proper documentation:

  • contribute to safer patient care?
  • decrease medico-legal risk?

Facilitation questions

  1. How does proper documentation contribute to safe patient care?
  2. How does proper documentation decrease medico-legal risk?

Suggestions to faculty

Attached is an example of poor documentation that you can copy and use as the basis of a learning exercise. Working independently or in groups, have learners identify elements in the document that may cause confusion or could be improved. What patient information is necessary to provide an adequate picture of the clinical situation?

Example of inadequate documentation:

October 7, 2105 h
51-year-old male
Vague chest pain
Stressed +++
Dx: Anxiety attack
Plan: Home on Ativan

Additional resources

CanMEDS: Communicator

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.