Physician Progress Notes Can Lead Directly to Costly Physician Error

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When you visit the doctor for one ailment or another, you want to place total trust in him or her. The doctor attended medical school after all or so, claims the framed diploma that’s displayed on his office wall. The doctor has been tested in medical centers and hospitals under stressful circumstances, and he is entirely educated on the latest and most sophisticated treatments possible.

But doctors are human, too, and although they take an oath to “cause no harm” to their patients, doctors are fallible. All too often, even their progress notes can lead to costly errors, which can result in something as traumatic as wrongful death.

Says the professionals at Seay/Felton, an Atlanta personal injury attorney, if you’ve suffered a personal injury due to another party’s malpractice, including medical errors, malice, or negligence, you could very well be entitled to seek out financial compensation in the form of a personal injury lawsuit. The proceeds you receive can provide you with peace of mind while you heal or, in the case of wrongful death, provide your grieving family with some comfort.  

That said, how exactly are problems with physician’s progress notes leading to costly physician errors? According to a recent report by MSN, the world of progress notes in 2024’s healthcare system, where empathy and precision are inextricably linked, can be an intriguing and worrisome one. This is because notes are much more than documentation. They are the words and sentences that create the entire story of patient care, including legal protections and successful communication.   

However, the system of physician notetaking is not a perfect one. Here are some of the problems physicians and other healthcare professionals can encounter with crafting patient progress notes.

Insufficient Detail

Insufficient detail is also known in industry circles as “The Okay Trap.” Just noting the three words “Patient doing okay” can present several problems. In fact, the words can come back to haunt even the best of physicians. But it’s a trap they freely enter, nonetheless. Think of ordering a meal at a restaurant, and what arrives is an empty bowl that has the word “spaghetti” written on it. Clearly, there’s something missing here.  

The key to doctors not falling into the “doing okay” trap is to be much more specific with their note-taking. The doctor needs to become a storyteller who can paint a vivid picture of the patient’s condition. Instead of jotting down “Okay,” it’s better to take the time to describe the patient’s condition and any changes, good or bad, that have been observed.

Solid wording, such as “patient temperature increased by two degrees…administering Tylenol,” creates a clearer picture and leaves no room for ambiguity. It can also prevent needless injury or discomfort on behalf of the patient for which the physician is responsible.

Neglectful of Timeliness

Being neglectful of timeliness is also known commonly as the “I’ll get to it later” syndrome. In today’s healthcare industry that’s crippled by a shortage of general practitioners and an influx of millions upon millions of undocumented aliens, it’s simply easier to get caught in the whirlwind of patient care. In other words, why bother taking notes now when you can do it later? This is not a good idea. 

It’s a far better idea to document what’s happening with a patient in real time. Progress notes are a way to capture the moment and create a detailed snapshot of a patient’s real-time condition. That way, they get the care they need now rather than later when it could be too late. Modern electronic health records or EHR record systems can assist an overwhelmed physician with this note-taking problem.

Not Including Important or Relevant Changes

Failing to take note of important changes in a patient is also known as the “Big Events Only” falsehood. It’s said to be human nature for a doctor to home only on a patient’s medical milestones. But this approach to note-taking can lead directly to the neglect of including small but nonetheless significant changes that can and will occur along the way.

Instead of overlooking the small details, physicians and healthcare providers need to pay strict attention to every change, positive or negative. When it comes to the modern healthcare system of the 2020s, every detail matters. To avoid needless personal injury to a patient, a doctor needs to include all important and relevant changes in a patient’s condition, no matter how inconsequential they might seem. Small changes are all too often indicative of larger, more significant trends.  

In the end, you must think of physician’s comprehensive notes as a single chapter in an entire novel dedicated to the patient’s life and health care. Each chapter should move the plot along and contribute to a clear understanding of the patient’s unique life story.