July 23, 2002

     "Unless you wrote it down, it did not happen." Thus every risk manager would tell you. Well, what about witnesses? They can lie, or forget, or like in many cases you and I heard about: they can be bought or shot.

     Medical malpractice is a bigger deal in some places than others. In the United States, unscrupulous lawyers get filthy rich out of them. And you can be sued for the most trivial of things and they can make you look real bad for some Good Samaritan thing you did for your patients. Some individuals or even families conspire and make a living out of it at the expense of medical staff. A single settlement can cost millions, loss of license and imprisonment. In consequence, medical insurance costs a lot of money--like buying a new car every year. And that is also why hospital risk managers and legal counsels clamp down a lot on documentation, because years later when you are facing the judge, all that can be seen is the patient’s alleged suffering and what was written in the chart.

     Perhaps rightly so, with all these horror stories of surgical instruments left inside some poor person’s belly, or having been given the wrong medicine, or being misdiagnosed and therefore incorrectly treated. Due to poor education and technology, it is hard to blame those poor rural folk that flock to faith healers and use herbs for undiagnosed collagen vascular disease, atypical mycobacteria, or heavy metal poisoning simply because we didn’t think about them or because we just don’t have the resources to diagnose them. Even if we do, they are too penniless to buy the medicines. Imagine what would happen in a poor third world country if all these poor folks sued the doctors for being unable to diagnose and treat them. It is hard to comprehend how many people actually died because of sins of omission in the medical field. Not to mention the sins of commission that was never revealed or recorded. In the US, it is estimated that more people die of malpractice and nosocomial related problems than all infections combined.

     But as we said, unless it is written, it did not happen. However, unless the patient’s folks know about the mistake, they will not sue. And not until they sue will the records be opened. Of course, not unless they are bought or threatened. So where does control lie? In you and me. There is still a book being written up there somewhere and there will be a day of reckoning somehow.

     On the lighter side, here are some doctor’s chart notes I found published somewhere, better left unwritten:

1. Patient has chest pain if she lies on her left side for over a year.
2. On the second day the knee was better and the third day it disappeared completely.
3. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.
4. The patient has been depressed ever since she began seeing me in 1993.
5. The patient is tearful and crying constantly. She also appears to be depressed.
6. Discharge status: Alive but without permission.
7. Healthy appearing decrepit 69 year old male, mentally alert but forgetful.
8. The patient refused an autopsy.
9. The patient has no history of suicides.
10. Patient has left his white blood cells at another hospital.
11. Patient’s past medical history has been remarkably insignificant with only a 40 lbs weight gain in the past 3 days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady pregnant.
14. Since she can’t get pregnant with her husband, I thought you might like to work her up.
15. She is numb from the toes down.
16. While in the ER, she was examined, X-rated, and sent home.
17. The skin was moist and dry.
18. Occasional, constant, infrequent headache.
19. Patient was alert and unresponsive.
20. Rectal exam revealed a normal sized thyroid.
21. She stated that she had been constipated for most of her life until she got a divorce.
22. I saw your patient today, who is still under our car for physical therapy.
23. Both breasts are equal and reactive to light and accommodation.
24. Exam of genitalia reveals that he is circus sized.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
27. Skin: Somewhat pale but present.
28. The pelvic examination will be done later on the floor.
29. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
30. Large brown stool ambulating in the hall.
31. Patient has two teenage children, but no other abnormalities.

Comments regarding this week's column are welcome. Please fill up the fields below and click Send to Author.

     The author's e-mail address is at docdan1@pol.net.

     All views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members. For comments, please e-mail the author.