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In Belgium, as you might recall, doctors are now being tried for euthanizing their patients without consent. A paper recently published in the Journal of Medical Ethics looked at the overall death rate in Belgium and found that a shocking 1.7 percent of all deaths in 2013 were related to the administration of life-ending drugs that were used "with the intention to shorten life and without explicit request."
In other words, doctors in Belgium are now taking it upon themselves to determine whether their patients should live or die, regardless of what the patients themselves think. Besides the fact that this amounts to murder, it also exemplifies how many in the Western medical profession view themselves as both judge and jury in the grand game of life.
Actually, documentation is a perfect example of the Goldilocks Rule: There can be too much or too little, but then there is the amount that is just right.
When you create a medical record, you create a legal document that is, in fact, one of the exceptions to the Hearsay Rule in that it is an out-of-court statement that can be entered into evidence as proof that what it says is true. Therefore, as I say when I lecture on medical malpractice, “You want to say things in your words because otherwise I, as the plaintiff’s lawyer, will be saying them in mine.”
First, write a note that can be read. As we move to full EHR this is less of an issue but still remember that you can end up being named in a case and deposed simply because your note, that would have otherwise explained your non-role, was illegible.
Since the only time you worry about documentation is when you either know that things have hit the fan or you suspect that they might, your first impulse will therefore be self-protection, and you will want to try to fill in every possible issue. This natural instinct will produce notes that are long narratives that go back into the past and are filled with extraneous facts that themselves serve not to explain the patient’s condition but your own conduct.
“Documentation is a perfect example of the Goldilocks Rule: There can be too much or too little, but then there is the amount that is just right.”
That is why you have to restrain yourself. Otherwise, you will create a statement that stands out from the rest of the record like a very sore thumb and will have just told a plaintiff’s attorney or board investigator where to drill.