If Your Documentation Suffers, 'So Has Your Defense'
ACEP News
September 2009
BY Doug Brunk
Elsevier Global Medical News
CORONADO, CALIF. -- In his dual roles as an emergency physician and health care lawyer, Dr. Michael Frank has observed an increasing number of patients seeking printouts of their medical records--and finding documentation that is incomplete, inaccurate, or completely wrong.
"If you want to spend more time with patients to the exclusion of certain documentation, that's fine," he said at a conference on reimbursement sponsored by the American College of Emergency Physicians. "Just understand that if and when you get sued--even though it may not be fair--if the documentation has suffered, so has your defense."
Dr. Frank, general counsel and director of risk management for Canton, Ohio-based Emergency Medicine Physicians, discussed the case of a 51-year-old woman who presented to the emergency department complaining of a dog bite laceration to the finger. The laceration was repaired under digital block, and she was discharged. The treating physician used an electronic medical records system to enter the details of her visit.
After receiving a printed version of her medical chart in the mail, the patient wrote notes of correction next to several items and returned it to the physician. For example, the vital signs and physical exam section of the chart indicated no evidence of significant external trauma. But in that section, the patient wrote "dog bite to hand."
According to the chart, she underwent an ENT exam, but the patient wrote that this "did not happen."
The chart also indicated that there was no evidence of local chest wall tenderness or external injury (patient wrote "never looked or touched"), and that the breath sounds were normal (patient wrote "never listened").
"We are seeing more complaints from patients who are saying, 'This didn't happen,' that the documentation was wrong," Dr. Frank said. "This is true, for example, for a review of systems. It has very little to do with our clinical practice, but it's a requirement for certain documentation. So, if we're documenting a review of systems that weren't really done, or we're doing an examination and we're documenting part of that examination that wasn't really done, we are opening ourselves up to fraud allegations.
"This is a trend," he added. "You'd better be careful that what you're documenting is exactly what you do, because patients are reading the medical record."
He went on to note that physicians who cancel the medical bill of a patient who may be unhappy with the services rendered or who threatens to sue don't necessarily put themselves at risk from a legal standpoint.
"The fundamental basic law of evidence in any litigation is that in order to be admissible, evidence has to be relevant," said Dr. Frank, who is also chairman of the board of trustees and an attending emergency physician at Summa Barberton Hospital in Barberton, Ohio. "The issue of whether you cancel the bill or not is not relevant to the issue of whether the care you provided was or was not below the standard of care. There are lots of different reasons for why you might want to cancel a bill. There is no algorithmic answer to when you should cancel a bill or when you shouldn't."
If you don't cancel a bill in a case where a patient is really upset, "that might lead that person to pursue a lawsuit," he added. "If you do cancel a bill, it's possible that they might interpret that as a sign of weakness or that you did something wrong."
If you believe the care you provided was inappropriate, "you should cancel those bills," he advised. "On the other hand, if you feel you didn't do anything wrong, then it becomes a matter of public relations and customer satisfaction. In the long run, it might be worth your time to foot that bill."