Bariatric Times July/August 2007

Bariatric Times • July/August 2007 Legal Perspective 11 the filing basket and doesn’t see the file sometimes for months. Review your transcription, make necessary changes or corrections, file continuously, and don’t let it pile up. The only way to eat an elephant is one bite at a time. Don’t let what is a series of small jobs turn into one big job you can’t handle and don’t want to deal with later. Legibility. Make sure that others can read what you’ve written. Lawyers can’t dispute it or defend it if they have no idea what it says! Most of the time when attorneys ask doctors or other medical professionals what they scrawled across the page, they can’t read it either! That’s a problem, and the plaintiff’s attorney will jump all over it. Juries don’t like it as well. It makes the medical professionals look lazy, uncaring, unprofessional, incompetent, and even stupid. That’s hard to counter, and exactly what a plaintiff wants the jury to think.4 Print everything if medical training has ruined your handwriting. Clearly label the chart and use appropriate writing materials. Every page of the chart should be clearly and accurately labeled with the patient’s complete name and medical record number. Individuals making entries into the chart should use pen rather than pencil, which can fade or become illegible, and create a presumption that the information was changed. Use ballpoint pens or the like rather than felt tips or fountain pens which can leak through the paper and cause bleed through over notes written on the opposite side of the page, or on adjoining pages.1 Put the year on dates in records. As many physicians see patients over a series of years, please be sure to put the year on any date entries in the record. If a patient is seen on December 10, 2004, and then not seen again until December 15, 2005, but comes in with a similar issue, it may appear in the record that the patient was seen on one day, and then returned for a follow-up or secondary appointment five days later, when in fact the patient was seen an entire year later for a separate incident altogether. Be thorough—include the year and make it easy on all the legal staff and yourself in the long run. Don’t use colored pens or highlighters. Colored inks tend to break down after time, and often do not copy well. Clear copies of the record are extremely important, so please don’t make it harder to defend your position. Similarly, if you are highlighting something in the record, please only use yellow highlighters. Colored highlighters obscure or even block the text underneath when copied. Yellow highlighters do not copy at all. We’d rather take the original record and hand highlight the copies to accurately reflect the original record than to try and mess with lightening and reproducing pages that are obscured by dark highlighters. The plaintiff’s lawyer always makes a big deal about not being able to read the record, and often makes allegations that the defendants were trying to hide something. Finally, never use pencil…it just begs for someone to claim the record was changed. Use standard charting symbols. Please do not make up your own charting symbols unless you clearly mark in the front of the chart what the symbol is and what it stands for. For example, there is no standard charting symbol for “bruising.” If you want to develop one, simply note it in the front of each chart so that other readers will know that symbol means bruising. If you want to use a symbol to represent the term “nutritionally deficient,” then make a note of it http://www.dalemed.com

Table of Contents Feed for the Digital Edition of Bariatric Times July/August 2007

Cover Editorial Message Table of Contents Editorial Board Letter to the Editor Malpractice Preventative Maintenance: Record Protocols and Happy Lawyers Resolution of Fibromyalgia Following Laparoscopic Roux-en-Y Gastric Bypass University General Hospital Bariatric Program at University General Hospital Journal Watch Category List Trade Name Index Company Index Products and Services

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