Template

Documentation Template

The purpose of this website is to improve doctor’s medical knowledge and documentation by reviewing real-life malpractice cases. In order to take this information and help physicians apply it directly to their every day work, I have created a Documentation Template. The Template serves to guide EM physicians as they write notes during a shift. I have also created a Documentation Rubric to grade physician’s documentation, which will guide the assessment of documentation on this website. The Documentation Template can help doctors improve the defensibility of their documentation:

This Template was created after reviewing numerous malpractice cases, peer review sessions, and M&M conferences. It is important to note that while the Template will address the vast majority of issues seen in malpractice cases, it is not a panacea. This is not a comprehensive or complete template for documentation, as it only addresses one of the 3 Goals of Documentation; defensibility. It is also not evidence-based.  You will notice that the Template applies only to the MDM (medical decision making) portion of a note. The HPI, ROS, past history, vitals, are where information is recorded, but it is not synthesized until the MDM. The other sections are for collecting the information, and the MDM is where you show how you synthesized the information together. (In the RIME model of medical education, the MDM is where Interpreter, Manager, and Educator components are found. The rest of the note is simply for being a Reporter). You certainly must document the other parts of the note to satisfy the billing and continuity of care goals of documentation, but when it comes to defensibility, the MDM is the most important. The MDM is where the core of your thought process and reasoning lies. While the Template above is not a comprehensive guide to documentation, it does provide guidance for some of the most overlooked areas of EM documentation. It will be a worthy guide as you seek to improve the defensibility of your charts.

2 paragraph method

One critique of documentation in the current healthcare system is that it takes too long. This Template seeks to guide the physician to high quality documentation without necessitating massive notes that takes hours after a shift to complete. Sometimes writing in an unstructured format can actually lead to longer notes. Long, unstructured notes can be more detrimental than helpful.

The Template can easily be split into two paragraphs of text. The first paragraph is written directly after you have seen the patient and placed orders. The second paragraph is written immediately after you have discharged or admitted the patient. Arranging your shift with the help of the template will not only improve your notes, but also provide a clear rhythm to your workflow. The paragraphs are as follows:

Paragraph 1 (written directly after seeing the patient):

Paragraph 2 (written after reviewing results and dispo-ing the patient)

With some patients, the entire note can be written at once, into one paragraph. This is especially true for the low acuity patient that does not need any testing, or the testing is already completed by the time you see the patient. However, the general principles outlined in the documentation rubric remain.

Good documentation leads to good care and defensible notes

Another important note is that good documentation and good care go hand-in-hand. If you are thoughtful as you write your note, your care will be better. Writing your note using this Template will help you consider your patient’s presentation, workup, diagnosis, and final disposition in a structured way that will help you avoid mental mistakes. Likewise, as you provide good care for patients, using the Template will help you remember to record all the excellent care you provided. EM physicians are notoriously bad at providing great care but forgetting to document it. What seems obvious at the time is often not obvious to others reviewing your care. The Template helps you get credit for the important assessment and decisions we make.

This Template is helpful not only in helping prevent bad outcomes, but is also helpful if an unexpected bad outcome occurs. Even in the case of a bad outcome, your good documentation will be protective. In regards to bad outcomes, no one expects EM physicians to be perfect. Every doctor will have unexpected bad outcomes. It’s the nature of what we do. It is not reasonable to expect perfection, even if the plaintiff’s attorney acts like it. What is important, is that even in the case of a bad outcome you can show that you thought and acted in a rational way. You can demonstrate that you acted just like any other reasonable EM doctor would have. And that’s where your documentation (and this Template) can be incredibly protective.  Many times litigious action happens years after the patient’s visit, and the physician may not even remember the situation. You are not likely to remember your thought process, so it is best to use this template to help record it in the medical record.

Consistently Good Documentation

Another benefit to using this Template is that it can provide consistency in your documentation. We often have a gut feeling about which patients may have something bad happen to them. The patient that is critically ill, those that leave AMA, etc… all seem like risky cases and we document in a very protective way about these patients. Unfortunately, most malpractice cases are a complete surprise to the physician involved. The cases that you think could result in a lawsuit often do not, and the ones that you never expected are the ones that cause trouble. Since you are unable to effectively predict which cases might lead to a lawsuit, it is best to build habits that result in consistently good documentation on ALL patients. Using the Template will aid you not just in documenting well on a few patients, but documenting well on ALL your patients. You cannot predict a black swan, so you need to form robust defenses against them.

Improve your odds

It is important to note that this rubric will not prevent you from being sued. It is not a magical shield of defense around your notes. You can be sued for literally anything. All someone has to do to sue you is fill out some brief paperwork and pay a small amount of money. That’s it. A patient can sue you because they don’t like the color of your scrubs or for any number of asinine reasons (hopefully these frivolous lawsuits will be immediately dismissed). The key is that good documentation makes it less likely that a plaintiff’s attorney will agree to the case, makes your case easier for your attorney to defend, makes your insurance company more likely to fight the case, makes it easier for an expert witness to defend you, and proves to the jury that you are a knowledgeable and thoughtful doctor. Documenting as suggested by this Template may significantly improve your odds, but nothing can prevent a lawsuit completely.

Conclusion

As you will see in the cases, the Documentation Template holds physicians to a very high standard. Many of the aspects of the rubric are things that seem so obvious to physicians they are hardly worth taking the time to write them down. And in >99% of patient visits, that’s probably true, given that you will never have to defend the chart to anyone else. But for the small percentage that you do have to defend your care, you will be extremely grateful that you followed the Template. The cost is several seconds of thoughtful reflection and a few lines of text, but the protection it may provide could alter the course of a career.