Charting Your Defense: Medical Records And Lawsuits

By: Robert P. Vogt

One day, the mailman hands you a certified letter and you discover you are being sued. The plaintiff alleges that he is a former inmate at a correctional facility where you once worked and that you failed to treat his illness appropriately. The plaintiff demands millions of dollars.

Lawsuits are, unfortunately, a common occurrence in the correctional healthcare environment. Many factors involved in prisoner lawsuits are beyond the professional's control. Judges, juries, opposing lawyers, and experts are some of the variables that the medical professional can not control. The professional does, however, control one critical area: charting.

Providing medical care in a correctional environment mandates that health care providers remain keenly aware that accurate medical records are essential. The thoroughness and accuracy of an inmate's medical records are often the best defense to an inmate's lawsuit. When interacting with an inmate, keep in mind that as you make an entry in an inmate's progress notes, you may be charting your defense.

I. The Purposes of The Medical Chart

The primary purpose of the chart is medical: to record the patient's symptoms, complaints, and treatment. The chart alerts subsequent healthcare providers of the patient's health status and course of treatment. The medication administration record, medical request forms, and outside referrals are also part of the chart. These documents are necessary to insure the inmate a continuum of appropriate healthcare.

A second purpose of the chart is legal. The chart is a business record. It is the best evidence of the interaction between the inmate and the healthcare provider. Because the chart is prepared simultaneously with the treatment provided and prior to the institution of litigation, the chart is typically afforded great weight by courts and juries.

Third, because of the high turnover rates in correctional institutions, the chart is often the only means available for a healthcare provider to recall the treatment provided to a particular inmate. Attempting to recall, several years later, a single interaction with an inmate can sometimes be impossible.

II. Proper Chart Entries

Every entry in an inmate's chart is important. In making chart entries, keep in mind that months or years from now you may be asked about a five or ten minute interaction. You may have only one relatively inconsequential contact with the inmate. And yet, years later, you are summoned to give a deposition, or to testify in court, to explain your entry.

For these reasons, complete and proper charting is absolutely essential. Making only a partial entry calls into question the veracity of the entire entry. Common sense dictates that if something is important, it is noted in the medical chart. If something is not recorded in the chart, the omission may lead to a swearing match between the inmate and the medical professional. Where a particular medical form requires an inmate's signature and the signature is not obtained, the inmate is free to claim virtually anything.

The S.O.A.P. format (subjective, objective, assessment, plan) is a good outline to follow with each interaction. The S.O.A.P. format reminds the professional to make different inquiries and attempts to insure that certain vital information is properly obtained and recorded.

Subjective

The subjective portion should contain any verbal complaints and statements. This section should reflect the reason the inmate has asked for medical care. It can be helpful to put the inmate's statements in quotes to insure that you remember that the words you recorded were the inmate's own characterization of his/her condition. Quoting the inmate's complaints also can help you defend an inmate's later claim that he told you about other conditions that you allegedly ignored.

Objective

The objective portion of the note should contain your observations, the inmate's vital signs, and the results of any physical examination. It is essential that the objective notes correlate, as much as possible, with the subjective complaints being raised by the inmate. If the inmate's subjective complaint is that he/she "feels hot", the objective portion should contain the inmate's temperature and skin moisture. The objective portion of the note should follow, and respond to, the subjective section.

Assessment

This section requires you to outline the effects of the inmate's objective symptoms. This section would include, if applicable, any diagnosis or conclusion. If an alteration in comfort is noted, it is critical to note why. If the inmate's complaints are not supported by the objective symptoms, that too should be noted. This portion of the chart should reflect the medical professional's opinion regarding whether the objective symptoms support his complaints.

Plan

The plan outlines the treatment, if any, provided to the inmate. This section follows the assessment and should be consistent therewith. It is important that the plan contain the medical professional's response to the inmate's specific complaint. It may be appropriate to simply note that the inmate is to be monitored or that the inmate's status will be checked in 4-6 hours. The bottom line is that the plan should be a logical conclusion to your interaction with the inmate.

III. The Chart's Use In Litigation

An inmate's medical chart is generally admissible into evidence and is often afforded great weight by the courts. Courts have held, in fact, that detailed medical records alone can be sufficient to overcome an inmate's post-suit allegations.

Medical charts also are relied upon by plaintiff's experts. If your charting is adequate, the expert may not take the plaintiff's case. Conversely, if your charting is not sufficient, an expert may take the position that he/she will not even consider your testimony because "in legal matters, I'm held to what I write." Such an approach again underscores the importance of thorough charting.

Finally, charting is the healthcare professional's best evidence of what actually transpired. While not a guarantee, proper charting can be one of your best litigation weapons. Keep in mind that inmates sometimes have a different view of what occurred. Memories fade. Also, the difference between what actually happened and what the inmate believes to have happened can sometimes "evolve."

IV. Conclusion

Lawsuits are an unfortunate part of correctional healthcare. There is no way to guarantee a suit-free practice. One of the best hopes for a healthcare professional is to practice thorough charting. Good record keeping will not only assist with providing a correct course of treatment, it may help you chart your defense.