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Linked to from defensive documentation

risk-reduction techniques
It is taught and re-taught at every level of medicine, sometimes under the label of “defensive documentation” sometimes as “risk-reduction techniques” or under other labels, and always with the understanding that a chart is a legal document. Patients who understand what is normal will be in a better position to realize when something about their care is not.

Theses are notes on recommendations from The American Academy of Family Physicians, one of the largest national medical organizations, on defensive documentation for physicians.

  1. To reduce risk, thoroughly document advice and instructions given to patients.

  2. A note that summarizes the thought process that led to a diagnosis is more defensible than a note that simply names the diagnosis.

  3. A common problem causing suits is physicians’ failure to follow through on tests recommended to patients.

  4. Failure to document a reasonable effort to rule out certain problems and clearly explain follow-up plans are pitfalls that lead to lawsuits.

  5. Failure to follow up on abnormal results and order appropriate diagnostic tests are among the problems associated with malpractice suits.

  6. Attorneys representing patients often point to physicians’ failure to order tests when nonspecific symptoms are present.

  7. Notes should be legible (which is in line with many court decisions too).

SOAP
The model evaluation sheet doctors use in charting patients is called SOAP (Subjective, Objective, Assessment and Plan). It includes:

  1. Subjective: The information given to you by the patient. Use direct patient quotes to demonstrate your attention.

  2. Objective: Measurable data. Supportive, reproducible observations.

  3. Assessment: Your appraisal of the patient’s progress, not only since the last appointment but an overall impression as well.

  4. Plan: How you intend to proceed. Include a brief rationale on why. What do you plan to accomplish with this plan?

It is important for patients to know where to find the above information when they need it. Otherwise they can be easily and completely manipulated, even to the extent of being blacklisted from getting treatment, a concept with which every patient must have at least a passing familiarity if we are to make any progress in patient safety.

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Correction to the syndicated column
The article says that when employees from the hospital became aware of this site they told me to remove it, and that when I refused, they sued. They didn’t tell me to remove it. No one ever contacted me about that. And they didn’t “discover” it. I wrote to the CEO of their corporation about it. I also wrote to a doctor in the hospital, a colleague of the offending surgeon, and told him about it (I was the victim of XXXX-XXXXX and XXXXXXXX and no one was paying attention to my complaints). But no one contacted me. If they had I would have worked with them to see if we could reach an accommodation. They abruptly went to court to get an injunction without giving me enough notice to get representation (the next morning).

I appeared in court alone and told them that I could be easy to get along with if only they would tell me what their problem was with my site. They wouldn’t discuss it. A far cry from anyone’s having contacted me and having me be the one who was unwilling. It was the reverse.

The false claim was repeated in the next column.