Defensive Documentation

Is there a skill more basic to medicine than getting the patient's history?

In medicine a great deal of attention is paid to the chart - from medical school onward. The clipboard containing the chart is one of the iconographic images of medicine. When a doctor comes in to see the patient he wears a stethoscope and carries a clipboard containing the patient's history on a chart. This is medicine at its most basic. This is where it all starts, or in some cases, ends.

Routine practice with regard to charts is defensive documentation and risk-reduction techniques. It is tailored to make medicine safe for healthcare providers. Defensive documentation is taught in medical schools. It is required by insurance companies and government agencies. Medical associations publish primers and refreshers to keep their members well schooled and up to date.

The core of this documentation, the chart, is the patient's history and the doctor's thoughts about what to do. It is important not only because it is ground zero for a patient's wellbeing, but also because it is a legal document. In our litigious and regulated world, charts are created with an awareness of how others might interpret them in the future.

Defensive Documentation

Defensive documentation includes not only gathering the patient's subjective observations, but also documenting the objective diagnosis, the advice given to the patient, and the thought processes behind that and the follow-up plan. The well-known acronym for that is SOAP.

A normal patient does not expect to be blacklisted by his or her doctor. A normal patient does not even know that is possible. Blacklisting is worse than the white wall of silence.

Currently doctors are not disciplined for failing to report unfriendly practices (see Dr. James Burt). They are not disciplined for refusing to help patients who have been injured by unfriendly practices (see Burt again). They are not even disciplined for taking advantage of a patient's trust in order to prevent him/her from getting help (see blacklisting patients).

Home | Table of Contents | It's a Path
Silence versus Patient Safety
Loyalty versus Patient Safety
The White Wall of Silence versus Patient Safety
Blacklisting Patients
Freedom of Speech for Patients
Medical Complaints - How to

* * * * *    < Truth / Justice / Patient Safety >    * * * * *
It's a path

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Revised August 18, 2008