Douglas Mossman, MD Dr. Mossman is director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and adjunct professor of clinical psychiatry and training director for the forensic psychiatry fellowship, University of Cincinnati College of Medicine.
How to reduce malpractice risk with better documentation.
Tips to make documentation easier, faster, and more satisfying” (Current Psychiatry, February 2008), I discussed documentation techniques at length. Table 3 reprints principles that may be especially helpful in practices that consist primarily of med checks.
Table 3
Keys to better documentation
Technique
Benefits
Time and date your notes
After an adverse event, establish when you saw the patient, recorded findings, wrote orders, reviewed lab results, or discussed problems with others can make a big difference in how your care is viewed
Sooner is better
Charting completed long after an adverse event occurred is vulnerable to accusations of fabrication
Brief quotes
Verbatim statements (‘I’ve never considered suicide’) quickly convey key factors in your therapeutic decision
Dictate or use speech recognition software
You speak faster than you write allowing you to document more
Provide handouts
Patients often do not remember or understand much of medication instructions doctors tell them
Use rating scales
Record more information in a scientifically validated format
Try macros and templates
These reduce documentation time and help you remember to cover everything you should
