The moment seasoned physician associate Dr. Chris Cannell, DMSc, MPAS, PA-C, DFAAPA, received a sheriff’s notice of a pending lawsuit, he panicked. It was the first time he faced the harsh reality of legal scrutiny, which became an important lesson on how documentation best practices are key to managing litigation risks. “I received a certified letter from a process server in uniform with no advanced notice, which in itself was traumatic. The personal impact of malpractice litigation on the individual provider can be life changing as a clinician,” he says.
Clinical skills and bedside manner are what matter in most cases as a clinician, but in a legal matter, documentation is often what’s under the microscope.
In Dr. Cannell’s case, his meticulous notes led to a verdict in his favor. “It was a lesson in the importance of documentation, practicing evidence-based medicine and showing empathy and compassion,” says Dr. Cannell.
Today, he works as a medical legal and healthcare consultant along with an expert witness for PAs and NPs.
Common missteps that lead to PA medmal cases
Patient outcomes can be unpredictable. When difficult circumstances result in a lawsuit, accurate record-keeping can be the difference between a defensible case and one that’s difficult to navigate.
In the case of PA malpractice, the plaintiff has to prove causation. This includes the following:
- A breach in the standard of care: Care that fell below what a provider with similar credentials, experience and training would be expected to reasonably know and do under the same or similar circumstances.
- Duty: There is an established patient/provider relationship.
- Injury or damages from negligence.
Dr. Cannell practices in high-risk fields of emergency medicine and orthopedic surgery, where negative outcomes can be unpreventable even in the best circumstances. Many clinicians today work in fast-paced environments even when care isn’t acute. As an expert witness and a consultant to other professionals, Dr. Cannell says moving too fast is one of the common causes of mistakes that lead to litigation. “In today’s fee-for-service model, people don’t spend enough time getting past medical history from patients,” he says.
Other complicating factors include cases where a patient is unable to share their medical history or where there’s a lack of communication in electronic medical record systems. Patients unintentionally may not share key factors in their past medical history because they may not remember or know their relevance or significance. In these cases, it’s important to do due diligence to try and obtain patient history from a relative or other physician over the phone. “It’s not always the patient’s responsibility to tell us the whole history. We have to know as clinicians to tease out that history from the patient because they’re not medically inclined. It’s our responsibility to ask the questions,” he says.
Of course, it’s important to practice evidence-based medicine and document why the clinician might not have access to a full medical history.
Finally, Dr. Cannell recommends treating patients with kindness and respect. This is a necessary part of clinical care that also helps mitigate lawsuits. “Even if you might do everything right, and the patient has an undesirable outcome, if you are not the kindest, compassionate person that gives them time, if you didn’t show invested interest in them, they’re going to notice that,” says Dr. Cannell.
PA’s documentation checklist to mitigate risks
Best documentation practices are important for patients’ continuity of care and safety. It also helps clinicians show evidence of due diligence in case of a lawsuit.
Following is a checklist for documentation.
- Be accurate and complete
Ensure all entries are precise and comprehensive. Missing details can be construed as negligence.
Whether you add notes after every appointment or at the end of the day, know what processes work for you. A delay in documentation can result in significant gaps that are hard to justify later.
- Include timestamps
Most EMRs include a feature to add a timestamp. This can be helpful for future care and demonstrating due diligence. Document patient interactions and treatments immediately or as soon as possible. Delays can lead to forgotten details and inaccuracies.
- Use objective language
Patients can access their records, so use objective, factual language rather than subjective or speculative terms. In the case of a difficult patient, use objective language to describe anything that might have impeded treatment.
- Note the use of evidence-based medicine
Document the tools, assessments and scales used to determine the course of treatment to show how you came to any specific conclusion.
- Document all procedures
It seems obvious, but Dr. Cannell sees many cases of poor documentation from previous providers. For example, one patient came with a necrotizing soft tissue infection from a dog bite that had been glued together. When Dr. Cannell went to comment on the procedure, there was no documentation of it occurring.
- Note any changes in condition or unusual vitals
Comment on abnormal vital signs in patient documentation. Also note any pertinent positive or negative lab and imaging results. “It comes up time and again in medical legal documentation. It’s very important to be able to defend against any abnormal vital signs, by commenting on abnormal vitals such as tachycardia, hypoxia and hypotension,” says Dr. Cannell.
Meticulous documentation, together with PA professional liability insurance, is a physician assistant’s best defense against litigation. Thorough documentation enhances patient care while also providing critical protection in the event of legal scrutiny.
