The Importance of Good Clinical Documentation and a Good Malpractice Policy

The practice of medicine is demanding, requiring total accuracy and focus, even in clinical documentation. It is both satisfying and fraught with potential landmines for all clinicians. This article was quite engaging for me, particularly because a portion of my career was devoted to emergency medicine.

Last Updated: 05 July 2019

Clinical documentation and medical malpractice

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By Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA

Blumm is a Surgical PA, National Conference Speaker, Author, Former AAPA Liaison to American College of Surgeons, Editorial Advisory Board Clinician1, Advisory Board POCN, Reviewer for Urgent Care Journal, Past President of four state and national associations. He is now retired.

The Case Report

Let’s get to the heart of this article in the first paragraph. The impetus for this article is from my personal reading last month and, in particular, Good Notes Can Deter Litigation, written by a renowned malpractice attorney, David M. Lang, Esq, in the April 2019 edition of Clinician Reviews.

The practice of medicine is demanding, requiring total accuracy and focus. It is both satisfying and fraught with potential landmines for all clinicians. This article was quite engaging for me, particularly because a portion of my career was devoted to emergency medicine.

As I read the presenting complaints and followed the development of the treatment plan, I found myself becoming angry with the plaintiff and attorney for bringing frivolous litigation. The assertion of the plaintiff is that the PA did not perform the functional exam.

The care of the patient, in my opinion, was by the book, excellent; I would not have called in my supervising/collaborating physician for such an everyday presentation. 

Do No Harm (and protect yourself, too) with Good Clinical Documentation

We have all taken an oath to “do no harm” and we are responsible to our patients to give them the best available care, utilizing our knowledge of disease and pharmacology.

What can seem to have been another day of rendering good care can, months or even a year later, become a living nightmare because of the unexpected subpoena we receive.

The nightmare can be exacerbated if we realize that we have absolutely no recall of the case. How do we access total recall? How can we defend our actions with all of the essential details?

The answer to both questions is with “good” clinical documentation. In this case, the PA had excellent clinical documentation from which he could testify as to following certain guidelines and administering the appropriate care and follow-up disposition. In addition to his documentation, he needed a “good” malpractice company.

He was soon to discover that neither his hospital nor supervising physician were culpable because of summary judgment. Additionally, the hospital was removed from the defendant list under a respondeat superior theory.

Why Consider Individual Professional Liability Insurance

The advantage to having a personal professional liability insurance policy derives from the fact that gaps remain. Other than limitations, there are legal findings that can remove other defendants from a case leaving you standing alone and in great need of legal counsel of the “highest” quality.

Throughout this article, I have placed two words in quotes: good and highest. Why? Because not all examinations, evaluations and notes are considered good.

And when it comes to representation at an examination before trial (EBT), a.k.a. the deposition, not all representation meets the same standards.

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Often Imitated; Never Duplicated by Robert M Blumm

How to Evaluate Liability Carriers

A “good” insurance company only hires a “good” attorney and if the criteria has been established, one can expect a” good” outcome.

In summary, I would highly recommend CM&F, who offers coverage with an A.M. Best A++ (Superior) Rated Company for your insurance needs.

CM&F has been in the business of protecting healthcare providers in all medical and nursing professions since 1947 and covering me personally for many years as well.

This insurance protects healthcare providers in defense of their license at depositions and represents them in a malpractice action.

About the Author

Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA

Blumm is a Surgical PA, National Conference Speaker, Author, Former AAPA Liaison to American College of Surgeons, Editorial Advisory Board Clinician1, Advisory Board POCN, Reviewer for Urgent Care Journal, Past President of 4 state and national associations. He is now retired.

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