AAO-HNSF Certificate Program for Otolaryngology Personnel

efforts, and test results. The pertinent information that must be recorded at the time of the call includes the name of the caller, date and time of the call, what was reported, any instructions or advice given, and any action taken. To assist in keeping track of this information, a small telephone pad could be kept by your telephone or in your pocket. Telephone messages recorded either in the office or after hours need to be added to the respective patient’s chart the following day. Avoiding omissions of information and time gaps is very important. Information most noticeably missing from medical records includes progress and/or operative reports, history and physical, vital signs, discharge summaries, and informed consent. Time gaps in the chart pose a serious defense problem. When these gaps occur, it allows the plaintiff’s attorney to focus on the missing times and claim negligence. If you are using preprinted forms, all blanks need to be filled in with either your findings or N/A or DNA. Remember, “If it’s not written down, you didn’t do it.” Documentation of medical mishaps should show that you promptly identified the complication, responded appropriately, and aggressively treated the complication and maintained appropriate follow-up. This documentation should include both positives and negatives. Documentation of medical mishaps should not include matters with legal implications or matters that are of no value to patient care or are related to risk prevention activities (i.e., completion of an incident report or notification of insurance personnel or your attorney). Finger pointing or blaming of others, otherwise known as “Chart Wars” (I called the patient’s internist four times, but as usual he did not call me back) does not belong in the chart. These remarks in the chart allow the plaintiff’s attorney to pit one doctor against the other. It also provides the plaintiff’s attorney with a potential “expert” witness testifying against you along with driving indemnity amounts higher. “Red Flags” include using words such as “mistake,” “error,” “inadvertent,” etc. In addition, conflicts or arguments with other treating physicians or nursing staff do not belong in the medical record. Tampering or changing a medical record to cover-up a mistake or mishap or to add new information in light of a pending lawsuit can be disastrous. You may feel the need to alter the record for errors in judgment that may not have been negligent and are not subject to recovery of damages. This includes inserting self-serving comments or observations. With the advances in chemical and spectroscopic examination of medical records, plaintiff attorneys are now using ink analysis to uncover alterations and determine accurate time dating of entries. Armed with this information, chemists are able to determine when the ink was produced and if it matches other entries in the medical record. Any appearance of changes or a cover-up will destroy your credibility in the eyes of the judge and jury, not to mention that you risk the possibility of non-renewal of your medical malpractice insurance by your carrier. Documentation of medical mishaps should not include matters with legal implications . . . Changes to Medical Records

Tampering or changing a medical record . . . can be disastrous.