The Disclosure Part 8

It’s important that patients’ medical records include clinical facts without speculation or blame. Document these conversations in the medical record by including at least:

• The date, time, and location of the conversation;
• All parties present;
• The clinical facts known at the time and communicated;
• All questions asked and answered;
• Steps taken to coordinate ongoing care—including collaboration with other physicians. An example of a related chart note would be “Discussed with the patient’s husband that Mrs. Smith will remain in the ICU for close monitoring over the next 24-48 hours.” Other physicians may be involved with the monitoring and may order additional tests;
• Record all services offered and accepted or declined by the patient and family such as social services, pastoral care, etc.; and
• Chart your commitment to share additional information as it becomes available, as well as the willingness you communicated to remain engaged.

Remember to keep your notes factual, concise, and professional; the medical record may be used as evidence during litigation.