The absolute best way to understand the extraordinary importance of “Proper Documentation” is to consider an actual case. The case discussed below involved surgery done 9 years ago, for a pelvic organ prolapse. More specifically, a repair of the prolapse using mesh.

Set forth below are segments of Cross-Examination relating to the mesh and relating to the surgery itself:

Q: Dr. Jones, I will be questioning you about your new version of what happened almost 9 years ago. That is, the version that you are giving in Court today as opposed to the version that you gave in your Operative Report 9 years ago.

A: Understood.

Q: Will you agree with me that your Operative Report has multiple substantive details that you now disagree with?

A: Yes.

Q: Was your memory better when you dictated your Operative Report at the time of the surgery ... or did it become better at your deposition 3 years later ... or did it become even better today ... 9 years after the surgery?

A: It got better today.

Q: Do you agree with me that an Operative Report must be an accurate document?

A: Yes.

Q: Do you agree that other physicians and health care providers “Down the Road,” may or may not rely on what you have written in your Operative Report?

A: Agreed.

Q: Accordingly, for the patient’s safety and welfare, it is extraordinarily important that your Operative Report be correct. True?

A: As best as possible.

Q: In this Courtroom, you now want to “Run Away” from your Operative Report ... True or False?

A: Not really.

Q: In addition to having misstatements in your Operative Report, there are also multiple omissions in terms of what you did? Can we agree?

A: Not really.

Q: Can we agree that before you signed your Operative Report and attested to its accuracy, you read the report and thereafter confirmed it to be accurate?

A: I thought I did.

Q: Will you agree with me that one of the crucially important aspects of proper record keeping is for continuity of the patient’s care?

A: Yes.

Q: We cannot have physicians calling each other on the telephone asking for interpretations of Operative Reports while surgery is actually ongoing?

A: That does happen sometimes. But certainly not ideal.

Q: Will you agree with me that an accurate Report should preclude the need for such Emergency Intraoperative telephone calls?

A: Maybe.

Q: Can we agree that one of the more important purposes of accurate medical records is so that subsequent treating physicians can have the ability to know what treatment was rendered?

A: Yes.

Q: Your Operative Report indicates that a “Patch” of mesh was placed within the hernia defect and that this patch was then secured to the fascia. Why are you now telling us something different?

A: Because the wording of the Operative Report is inaccurate.

Q: Can we agree that what you are telling the Jury now is different than what was written in your Operative Report?

A: Yes.

Q: Can we agree, Sir, that what you are attempting to do now is create a Coverup?

A: Absolutely not.

Q: Dr. Jones, aren’t you rewriting your Operative Report in terms of your testimony so as to be found not guilty of malpractice?

A: No.

Q: You testified before our Jury that you did an underlay of mesh. But this was not referenced at all in your Operative Report?

A: That’s correct.

Q: There is no written evidence to support your new testimony ... am I right?

A: Yes.

Q: In your Operative Report you described the procedure as “Palliative.” But this patient had been cured of his cancer 6 years earlier.

A: Yes.

Q: You used the word “Palliative” to describe this hernia repair because you were attempting to communicate that this was a temporary repair ... not a permanent repair?

A: That’s not true.

Q: Can we agree that there is no other reason to describe a Ventral Hernia Repair as “Palliative Surgery,” other than to communicate a short-term repair?

A: No. That is not true.

Q: Can we agree that Palliative Surgery is not meant to last long-term?

A: Sometimes yes, sometimes no.

Q: You now come to Court and claim that the patient’s alcoholism caused and contributed to the poor wound healing and the ultimate dehiscence and infection. Can we agree that there is not one word in the Hospital Chart nor in your Office Chart demonstrating that any of the health care providers were concerned about the plaintiff’s alcohol intake.

A: I agree. I don’t see a Note.

Q: You also attempt to blame your patient for not using the Wound VAC as prescribed. Do you see any Note in this 5,000-page Hospital Chart which indicates that your patient was not using the Wound VAC properly?

A: I don’t see such a Note.

Q: And now you’re once again trying to throw the patient’s case out of Court based upon something that you made up after you were sued. True?

A: Not at all.

Q: Can we agree there’s nothing in the chart indicating that the Wound VAC had to be worn 24 hours a day?

A: That’s true.

Q: But now you’re telling our Jurors that it had to be worn 24 hours a day?

A: True.

Q: But none of this is documented?

A: True.

Q: Were you too busy to document?

A: No.

Q: It is not disputed that this case centers around an infected mesh which resulted in septicemia and permanent injuries. Can we agree that there are absolutely no Notes reflecting any consideration to bring in an Infectious Disease Physician?

A: No Notes. But we did consider an Infectious Disease Consultation. Just not written down.

Q: You’re now saying that because you’re on trial. You never documented that at the time. True?

A: Yes.

Q: Can you agree with me that everything that you are trying to tell the Jury now is not supported by the medical records?

A: Some of it is.

Q: Why are you trying to sell us on a new set of facts that appear nowhere in the medical and Hospital records?

A: Just because it is not written, doesn’t mean that it didn’t happen.

Believe it or not, many, many cases are won by plaintiff’s counsel based upon poor/inaccurate/missing information documented in medical/hospital charts.

Please don’t let this happen to you!