MD News: Poor Documentation: the Heart of the Problem

by | Feb 26, 2019 | Medical Malpractice | 0 comments

By Peter T. Crean and Nicole S. Barresi

Tuesday, February 26, 2019

Detailed documentation is often the best protection from litigation; however, there is increased importance to have detailed documentation when the patient is unable to fully describe their symptoms and/or when the patient or guardian has direct access to clinical notes. This exposure is likely to become prevalent in subspecialties, such as pediatric cardiology, in which patients often have transient symptoms that they are unable to fully describe and can be distorted by parents’ heightened concern regarding their child’s complaints.

While most patients do not currently have access to physician visit notes, transparency is trending in medicine. OpenNotes estimates that over 34 million patients have access to their clinical notes, with a goal of increasing that number to 50 million by 20201. While the Health Insurance Portability and Accountability Act already provides patients the right to an examination of their medical records, typically patients have not done so because it can be difficult to navigate the procedures. With the advancements in technology, however, many providers’ notes are now available to patients via online portals that can be accessed anytime from a computer or smartphone. While the benefit of this enhanced transparency is improved compliance with treatment plans, providers should be aware that there will be increased scrutiny of their notes.

This is particularly true in pediatric cardiology. Parents are highly sensitive to a physician’s visit notes for their child. We expect that inaccuracies or mischaracterizations in these notes will result in calls to the office seeking explanations, and parents’ heightened concerns that their child’s symptoms are being misinterpreted or overlooked.

A close review of notes will occur when parents feel that a condition is not adequately investigated or explained. Pediatric cardiologists often receive referrals for patients with complaints of chest pain, arrhythmias and/or syncope. It is crucial that providers are cautious in their documentation of these histories and examinations. While chest pains of a cardiac etiology are rare in children, it is important to document patients’ extensive health histories, physical examinations and all conversations with patients and/or guardians. Healthcare providers should also consider documenting the serious conditions they have ruled out, such as, left ventricular outflow tract obstruction, hypertrophic cardiomyopathy, myocarditis, pericarditis, Kawasaki disease, and any referrals for additional consults as these symptoms are more often related to GI disorders, infection or trauma to the chest, costochondritis, exercise-induced asthma, drug use, and/or psychiatric issues2.

Transient complaints of palpitations, arrhythmias or syncope with and without activity are often most concerning. Unlike adult patients, children are often unable to provide a high level of detail in describing their symptoms, and their episodes may be shorter and more remotely separated. If an arrhythmia can be found on an electrocardiogram or if a vascular anomaly is seen in imaging, then management can begin. However, vague complaints of an irregular heartbeat or fainting with a normal electrocardiogram are frequent occurrences. Here, it is important for providers to extensively document the history provided by the patient and guardian to fully capture the clinical picture at the time of the assessment. When reviewing a patient’s history providers should consider documenting: a chronology and description of the symptoms, activities preceding the event(s), previous episodes, dietary and sleep history, and any personal/family history of cardiac disease. Obviously, it is also important to thoroughly document any findings from a physical examination, cardiac monitoring or testing performed, any detailed conversations held with the guardian/patient, and conditions ruled out — especially life threatening etiologies — given the tendency of presentations to evolve.

The field of pediatric cardiology receives a number of referrals for issues that are often transient, poorly described, unlikely to occur in the presence of the provider and have strong guardian advocates who will investigate all information available regarding their child’s condition. As transparency increases, detailed visit notes are the best defense for litigation and frequent calls from guardians.

  1. org
  2. Dick II, MacDonald, “Common Problems in Pediatric Cardiology,”

Source: MD News February 2019, Long Island Edition