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Documentation


Document, document, document!

Problems and pitfalls


Informal interactions

Information given or received by telephone without documenting it is often forgotten, but can be vital to both patient and doctor.

Similarly, informal discussion (for example in the corridor) may lead to a decision to do or not do something. If there is an adverse outcome, the reason for that decision may be questioned. If there are no notes, it is likely the details will be forgotten.

Correcting the medical record

There are times when information is entered incorrectly — perhaps on the wrong patient's record by accident or perhaps due to a misunderstanding or just a "slip of the pen." Corrections can be made, but must be done properly to avoid an appearance of deliberate falsification.

On a paper record:
  • Cross out incorrect information with a single line, date and initial it.
  • The original information should still be legible.
  • Write the correction and the date you write it.
  • If there have been subsequent notes, place the correction after the latest, date it, note the date of the notation being corrected and include the reason for the correction (new information, patient corrected self, etc.).

NEVER make a correction or change an entry after learning of a complaint or legal action.

On an electronic record:

  • Indicate the reason for the change.
  • Enter the correct information.
An EMR should have an audit function that will indicate who made any entries or changes and when. If the EMR allows deletion, it should store and permit access to deleted text.

NEVER allow others to use your password, use someone else's password, or make changes after learning of a complaint or legal action.

Lost, misfiled, or misdirected documents

A common cause of legal action in a doctor's office is failing to deal properly with lab or diagnostic imaging reports. It may be because the test or investigation:
  • wasn't done
  • wasn't reported
  • report was not received
    • was not sent
    • was sent to the wrong place
  • report was not read
    • was filed before reading
    • was "at the bottom of the pile"
  • report was not acted upon
    • significance not recognized
    • incidental finding not related to reason for test
    • patient did not return
Such problems can occur in hospitals, community services, clinics, and offices.

Case: A lost test report
Shelves with medical records

Background

A woman booked for tubal ligation (TL) has a pre-op exam at the hospital. A PAP test is done.

A week later she is admitted and the TL is performed uneventfully. The PAP test report is not included in the chart.

The patient does not see the doctor again and when the health authority closes the hospital all records, including lab tests, are put into storage.

Outcome

A year later the patient is found to have cervical cancer. The original PAP test report is located. It shows severe dysplasia. The patient dies 18 months later.

Think about it

What system processes might prevent this from happening again?

Lesson learned

An effective tracking system in the physician's office would have identified that the PAP test result had not been received. This would have alerted the physician to follow up the result. He would then have contacted the patient for further care.
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Hospitals have a duty to file test results in the medical record in a reasonable time.

Doctors in their own offices should have a system to track, file, and deal with test results.

Case: An important arrhythmia
Two EMS attendants working on female patient on stretcher

Background

An emergency physician diagnoses a concussion on a teenager who fell and struck her head after fainting. The paramedics note a rapid dysrythmia that resolved. The emergency physician notes a borderline abnormal QT segment on the electrocardiogram (ECG). He forwards a copy to the pediatric cardiologist for a second opinion.
Long QT reading

Background continued

The cardiologist highlights the abnormality and documents a possible long QT syndrome on the ECG report. There is no direct communication between the two physicians.

The cardiologist intends to send the report back to the emergency physician. However, it is inadvertently sent to an uninvolved physician with the same surname but different initials. The patient's family physician also does not receive the cardiologist's report.

A year later, the patient suffers a fatal Torsades de pointes arrhythmia.

Lessons learned

This case highlights several communication failures:
  • There was no direct communication between the emergency physician and cardiologist.
  • The cardiologist did not phone or fax the emergency physician to advise him about the potentially serious ECG abnormality and arrange for follow up.
  • The ECG report was inadvertently forwarded to an uninvolved physician, who did not redirect it to the appropriate physician.
  • When the emergency physician did not receive the ECG report, he did not follow up with the cardiologist.
  • The family physician did not receive the ECG report.
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