The Devil Is in the Details

I have written many times about the importance of thorough documentation (in fact, this may be becoming the general theme of my column). As much as it does not serve to beat the proverbial dead horse, I have reason to visit that topic again. I was recently called to give my opinions on standards of care in a deposition for a malpractice case. While on vacation, the patient had seen another practitioner – this doctor called her regular treating doctor and got a slew of treatment notes. He then rendered care he felt was very similar to what was reflected in the provided records.

However, the patient felt the care was different – enough so that she didn't like the care provided and sued for bad treatment that caused her pain. I was asked to review the notes provided and give my opinion as to whether the doctor the patient had seen while on vacation acted within a reasonable standard of care or negligently.

What became apparent during the file review process was that the "vacation" doctor (in my opinion) did act responsibly – he requested previous treatment records and narrative reports. He took the time to review the records and compared those findings to his own quick patient assessment. He relied heavily on the provided records to establish a baseline rationale for his treatment. The bigger problem was that the "back home" doctor kept pretty poor notes, and the records sent did not give a good representation of the patient's condition, including an old spinous fracture at C7.

During my deposition, I was asked a number of questions by both sides. These questions provide good insight into how the legal realm looks at your records, and what they expect to see.

One of the first questions posed was: "Is it fair to say that good record-keeping is essential to being able to provide good patient care, and to prevent injury to the patient?" Realize what is being said there – good documentation is integral to good care. The corollary to that is good documentation is necessary to keep a patient from being harmed. If you are not keeping good records, you are legally viewed as not providing good care and potentially jeopardizing the well-being of your patient.

At a point in the interview, the doctor noted that he had recently changed his office practice and started using electronic records. The attorney allowed the doctor to explain that this had become necessary due to insurance billing requirements, and also the changing health care laws. The attorney again postulated that these rule changes were to ensure good documentation and show good care – and that not providing good documentation could potentially harm the patient.

At several points in the record, another practitioner noted that "previous medical records will be requested for review." This sounds good at face value, but the follow-up question posed by the attorney was: "Well, how do you know these records were ever requested or reviewed?" Unfortunately, there was no good answer to the question. The doc had recorded that he intended to request the notes – but it was not recorded that he had requested them, if or when they had been received, or if they had been referenced or reviewed.

The lesson here is that when you make a note about other medical records, follow through – get those notes, include them in your file, and reference that you have received and reviewed them in your own records.

The next issue that was brought up was technique. The records provided only stated that "manual full spine treatment was provided." Again, that is simple and general, and sounds good, but is not adequate. Questions that were asked by the attorney at this point included: "What technique was used in the lower cervical spine?" "How do you know?" "What segment was manipulated?"

The general "umbrella" comment that "full spine care was provided" did not answer any of those questions. There was no credible way for the doctor to recollect those minute specifics. Since that information was not well-documented, the care provided was considered questionable at best.

Many other questions were asked and debated during the course of this interview, but I hope I have shared how the medical-legal realm looks at our documentation. The attorney in this case made it very clear that appropriate documentation must be complete. The omission of small details can become a big issue. When caring for a patient, it is your responsibility to accurately document all components of the care you provide:

• Your consultation must be relevant. Comments like "good" or "worse" are inadequate. What has changed specifically since they were last in? How have they felt better? More active? Less medication? These are minor details that make a big difference in how accurate your records are. If the patient has not been in for awhile, make sure you discuss what has changed in the interim. Take the time to document the changes since their last visit.
• Your findings must be current. During your evaluation, note if muscle tone has changed – better or worse? Are the subluxation findings different? Is range of motion better or worse? You do not need to do a full exam every visit – but it is reasonable to expect that there would be some progressive changes in the patient's status with the care you provide. Make sure that is clearly documented on each visit.
• Don't trust someone else's notes. Recall that in the case I discussed above, clinical judgment was made using someone else's poor records, and the doctor who tried to provide good care ended up getting sued. Is it your responsibility to fully assess any patient you see before you provide them care. Based on the subjective comments of the patient and your objective review, give a straightforward rationale for the treatments you provide on that date.
• Your treatment notes must be specific. Don't fall back on generalities. Remember, "full spine care" is not appropriate. If you provide therapies, make sure you state what therapies were provided and to what body part(s) they were provided. Note what soft-tissue treatments were provided, and name the tissues treated. Name the segments adjusted – not just general spinal regions. With rehabilitation, define the exercises performed. Also, when you list the procedures you provide on a given date, I recommend you itemize them in the order performed; this shows a flow of care, not just a list of procedures.

At a point this may seem like a lot of information to manage, and it is; but all of this data is relevant and important as part of the care you provide. Thorough documentation is part of good patient care. Think of these notes like a fire extinguisher: you don't want to have to deal with it, but when you need it, you are happy to have it there.

During a deposition, an attorney can ask you just about anything about your care of that patient, whether or not you wrote it down. What you "think" or "remember" is not credible – if it is not written down, it is not part of the record! If you are ever called upon to justify the care you provided a patient, the notes in your file will be the only tool you have at your disposal. Make sure you take the time to complete your documentation. As I've said before and will say again, it's good practice and good patient care!