Michael J. Sacopulos, Esq.
It was tennis star Andre Agassi that said “Image is everything.” Okay, he overstated it, but Andre did have a point.
Image matters. But does it matter for an expert review of a patient’s chart in evaluating a potential medical malpractice case? The answer is no one knows…yet.
As general counsel for Medical Justice, I thought it might be useful to the members to offer tips on charting. I am not a physician and I do not pretend to know what medically relevant information should go into a patient’s chart. I have, however, seen my share of charts involved in litigation. I know presentation of information is often as important as the information itself. With the help of a sociology professor, I began to research what studies had been conducted on presentation of information in medical charts as it relates to liability. What we found was exactly zero.
Although almost every medical malpractice case begins with an attorney hiring an expert to review a potential case, no one had ever studied the impact of charting. For example, is an expert more likely to say the standard of care has been breached if a chart is handwritten as opposed to typed? What difference would it make to the experts analysis if the chart included comments about a patient being verbally abusive to the receptionist? My guess is that there are any number of “non medical” factors that impact an expert’s opinion on the medical care rendered.
With the help of Medical Justice, Indiana State University Professor Tom Steiger and Erik Southard, I am in the midst of surveying physicians on these issues and others. I am looking forward to sharing the results with you. For now, let’s just say that you probably want to keep your transcriptionist.
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I have reviewed thousands of charts over 25 years and before an expert ever sees a case I do an analyses. Handwriting, while often difficult to decipher, becomes a lot easier when you understand what usually goes into notes. Secondly, Typed notes are easier, obviously, but they have no bearing on whether I think there may or may not be liability.
We need to remember that medical records are the property of the treating physician and are intended to make the treatment safe and effective, which is not the same as being part of a ritual of placating or paying tribute to the insurance industry or bowing down to various malpractice goons.
If I choose to make cryptic designs in my (handwritten) notes that have meaning to only me, then I should be allowed to do so. I am obligated to take good care of my patients, not make picture-perfect medical notes.
We should be allowed to insist that patients give consent, irrevocably, for notice of bad conduct such that if they give consent for release of any part of the medical record, then notice of such undesirable conduct gets circulated with it, too. That way, patients who sue and are found to have filed a frivolous case, who smoke but do not pay their $3 co-pay on Medicaid, who try to bully the physician into signing an unreasonable note for the electric company to steal electricity, or who otherwise obstruct ordinary office activity, will be forever marked as having done so if their medical records go anywhere–including to a jury. If physicians are to be held accountable, so should patients.