January 2005

What NOT to put in patient records

by Timothy Feuling, CBS President

For the past several years, I’ve been telling doctors about the importance of proper record keeping. Every examination, patient consultation, report of findings, adjustment, and problem needs to be thoroughly documented.

But there are a few things that shouldn’t be put in your patient records. Mainly, these fall into four categories:

1) Non-care-related issues. Any information that doesn’t directly involve the actual care you provide (including examinations, tests, adjustments or other chiropractic procedures, recommendations, consultations, etc.) should be kept in separate files. This includes billing and insurance records. In case of lawsuit, patient “medical” records can be subpoenaed. Your notes on late payments, billing disagreements, insurance inquiries, etc., need not be handed over to the plaintiff’s attorney unless they are a part of the actual patient records. This is particularly important since it could be claimed that you mistreated the patient (physically, mentally or professionally) due to billing problems or some non-care issue. Such matters may come up in court, but you don’t want your private records being used against you.

2) Personal opinions. When you’re writing your report on a patient, it’s easy to jot down a comment like “wants to get out of work” or “sounds like a hypochrondiac to me” or “lawyer – litigious.” Your personal opinions –

even your ‘gut instincts’ about a patient – are important factors and shouldn’t be ignored. But they shouldn’t go into the patient’s records either. As in non-care related items, you don’t want to have those comments made public in court. Your records should contain only the facts, test results, professional observations.

3) Comments about other doctors or treatments. After talking with a patient, you might come to the conclusion that the care he or she received from a previous health care provider was substandard. If serious enough, you might consider a board complaint, but it’s best not to play the ‘blame game’ in the patient records. By doing so, you open yourself up to problems down the line should your comments become part of the court record. This is doubly true for comments about other doctors or staff in your own office. Occasionally, a doctor will try to shift blame to a CA or an associate or colleague when something goes wrong, but doing so not only sows seeds of discontent within the office, but could give the plaintiff ammunition to use against you in court.

4) Supplemental Complaint/Claim Information. Any material dealing with a board complaint or malpractice demand/claim. This includes all reports, such as "my side of the story" narratives used to explain an incident to an adjuster or board investigator, expert reviews of your patient handling and all correspondence to or from your board, the insurer, or your own defense attorney. These papers and notes should be in a separate "claims," or "complaints" file - NOT in the patient file.

4) Unprofessional comments. This includes everything from assessments of the patient’s personal appearance to doodles and sketches (all of which have been uncovered in doctors’ records during court!).

In short, when you prepare your notes, either by hand or on your computer, picture a plaintiff’s attorney reading those notes in court, for the world to hear. Your professional obligations are to maintain thorough and accurate records about the care you provide your patients. Anything else should be kept out of the records.