“Doctor, let me see if I understand what you’re saying. You just told the court that Melanie was febrile, was much less active than usual, and wasn’t eating. You also testified that these can all be signs and symptoms of bacterial meningitis, a life-threatening illness. Yet you ordered no tests and prescribed no antibiotics. Instead, you told little Melanie’s parents that antibiotics wouldn’t help and that all she needed was Tylenol for the fever. But you were wrong, weren’t you, doctor?”
When emergency care is scrutinized for medicolegal purposes, the chart plays a key role in the decision-making process. This is because charting is contemporaneous with the encounter, and, unlike memories, the chart does not fade or change with the years that typically intervene between treatment and litigation. The chart is pivotal in a plaintiff’s attorney’s approach to a case, vital to the defense attorney’s charge, and often the primary (if not only) source of a practitioner’s memory of the medical encounter. The million-dollar question, then, is what will that chart convey to the reader? Will the jury be able to clearly see the encounter in the way the physician did at the time the care was given? If not, will the jury base its decision on facts, emotion, likability of the parties and their attorneys, credibility of “expert” witnesses, or a combination thereof?
The story told by the chart is often a mere skeleton of the actual encounter, which not only represents a missed opportunity for communication between providers, but also can become a dangerous medicolegal pitfall. Multiple factors conspire against thorough documentation in the ED, including time pressures, pattern recognition, coding components, and the limitations and shortcuts found in the various charting systems. However, it behooves the emergency physician to develop a habit to capture relevant quotes and specific behaviors that occur during the patient encounter in a way that will speak not only to the author several years and several thousand patients later, but also to the patient’s primary care physician scheduling a follow-up visit, a plaintiff’s attorney deciding whether to pursue a case, and a jury deliberating on the possibility of medical malpractice.