Tips for Improving Physician Documentation

ED Physicians... want to avoid a malpractice case? Record your consult times. ___________ I review a lot of medical malpractice cases. A VERY large percentage of these cases involve ED physicians (or PAs/NPs) consulting specialists for guidance, admission, etc. One problem I see CONSISTENTLY is the lack of adequate documentation about these consults. More specifically... the note does not reflect the EXACT time the consultant was called... EXACTLY what was discussed... and EXACTLY what the next steps in management were. Why does this matter? It is very common for a consultant to say in deposition, something along the line of "The ED doc never mentioned that"... or "I didn't get a call until an hour after the CT was done"... etc... So... please don't rely on the time stamps in the medical record... or the unit clerk properly documenting the time of the call... or the "recorded line" we all think is listening to us.... all of these things will conflict with each other and are usually wrong or missing. Instead, have a notepad at the desk... write down the time you made the call... the time the call was returned... and a quick outline of what was discussed. Then, when you complete your EHR entry later... it's all there. This is not "defensive documentation".... I really dislike that phrase. This is "accurate documentation" that will keep you off the stand and maybe even prevent being named and deposed. (If you need an example, DM me and I'll guide you to a plaintiff podcast episode released this week where this exact scenario saved the ED providers from being involved in a really bad case.)

A physician colleague recently asked me: "What's the one thing emergency physicians could do to reduce their malpractice risk?" My answer surprised them: "Document your thinking, not just your conclusions." In reviewing cases, I've noticed a pattern: Physicians who document their clinical reasoning - why they ruled out certain diagnoses, what specific findings reassured them - fare much better than those who simply document conclusions. Compare: "No evidence of fracture" vs. "No point tenderness, normal ROM, weight-bearing without difficulty" "Viral syndrome likely" vs. "No focal findings, normal vital signs, good hydration status" The difference is subtle but powerful. The first documents only the conclusion; the second reveals the clinical reasoning. This simple documentation approach demonstrates thoughtful care and makes it much easier to defend reasonable clinical decisions, even when outcomes aren't ideal. #RiskManagement #MedicalDocumentation #PatientCare

Serving as an expert medical witness has profoundly changed the way I document patient encounters. Reviewing complex medical cases from a legal perspective has shown me repeatedly how critical clear, thorough documentation is—not just for patient care, but also for protecting physicians in legal scenarios. From recent cases I've reviewed, here are three documentation habits I'd recommend to every physician: 1. Clearly document your rationale: Explain the clinical reasoning behind decisions. Instead of simply noting “ordered imaging,” clarify why you chose that specific test. 2. Record patient interactions accurately: Detail discussions about risks, benefits, and alternatives—especially when patients express hesitation or preferences. 3. Stay timely and consistent: Gaps, delays, or vague notes (e.g., "patient doing better") leave room for interpretation. Precise descriptions help protect you and provide better continuity of care. Being an expert witness has not only strengthened my clinical documentation—it’s also given me a deeper appreciation for clarity and detail in medicine. Physician colleagues, what documentation practices have you adopted to keep both your patients and yourself protected? #MedicalExpertWitness #MedicalDocumentation #PhysicianAdvice #HealthcareLeadership #RiskManagement