Which physician’s chart says “No Cause of Action” to you?

A: “Patient alert, exam of pupils/CN/strength/sensation/reflexes/gait nonfocal.”

B: The same exam notes followed by: “Patient drinking juice; propped on elbows, coloring. On otoscopy, resists vigorously, calling me a ‘stupid-head.’ Relents when mom threatens to withhold dessert. Running down hallway after exam.”

The plaintiff’s attorney reviewing Physician A’s chart sees an opportunity. The generic, unindividualized “medicalese” introduces uncertainty that is unfavorable to the defense. The attorney knows that few jurors are literate in medical jargon; this creates a vacuum in a jury’s understanding of the case, giving the attorney an opportunity to convincingly present the plaintiff’s point of view.

On the other hand, the plaintiff’s attorney reviewing Physician B’s chart foresees an uphill battle: This chart portrays a child who is strong, active, feisty, and possessing the ability to reason and weigh options. It also illustrates the mother’s perception of the child’s wellness at the time. This feat is accomplished by documenting a few specific observations, accessible to laypersons, thus bringing the chart to life as a supportive witness to medical decision making.

Some of the many instances where a storytelling approach is valuable include:

• The patient who is being held involuntarily: “Patient states, ‘I’m going to shoot myself when I go home’ ” is more effective than “positive for suicidal ideation.”
• The difficult patient: Use exact quotes to convey the substance of the encounter, rather than characterizing a patient as “rude” or “abusive.”
• Documenting informed consent: “Patient says, ‘I understand that I could die and I want to go home’; wife, daughter, RN Smith present.”

While it is neither practical nor advisable to treat the medical record solely as a medicolegal device, using a few key phrases to document specific behaviors can make the difference in prevailing in (or even better, avoiding) a malpractice suit. Those who rely primarily on the chart to understand what happened during a patient encounter long after the fact will be able to better understand the circumstances. Because a physician’s resources are best spent fighting disease rather than legal battles, this sort of proactive charting is a critical part of effective care and risk management.