Magazine article Medical Economics

Malpractice Consult

Magazine article Medical Economics

Malpractice Consult

Article excerpt

Be careful when writing notes about patients

After a cantankerous patient's recent visit, my partner jotted on her medical chart, "Hypochondriac who doesn't pay her bills!" I worry that this could get us in trouble if she ever sues us. Am I right?

Yes, you are. The tone of your partner's comment is much too inflammatory to be in any patient record. Only notes relevant to medical care belong in medical records. Keep comments not related to treatment, such as billing information, in a separate file.

You wouldn't want such information to fall into the hands of a plaintiff's attorney who requested the records. If the patient sued you for malpractice, the "hypochondriac" comment might lead a jury to think that you and your partner didn't take her complaints seriously. And the remarks about her bills might indicate that you were more concerned with money than her health. Patients in many states have a right to copies of their records, and such remarks would certainly anger them.

When to let the insurer know about a request for records

Attorneys for patients often request copies of records. Am I supposed to notify my malpractice carrier each time?

Review the chart and determine whether there's any chance a malpractice suit could be brewing. For example, if you treated the patient for injuries sustained in an accident, or if the records are requested by a defense attorney, there may be no need to notify your carrier.

However, if you think questions could be raised about the quality of your care, if the patient has had a bad result or is unhappy, or if you're unsure of the lawyer's intentions, report the request. Your carrier will probably interview you and secure the original record in a locked file so it won't be lost, damaged, altered, or destroyed. It's to your benefit and the insurer's to get an early jump on a potential lawsuit, while your memory and that of other witnesses is fresh and while the records are still available. …

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