QUESTION:
A physician on our Medical Staff has made numerous entries into the EMR critiquing hospital staff.  We have approached the physician several times to inform her that a patient’s medical record is not an appropriate forum for these comments, but she claims that as the attending physician she has the right to put whatever she wants to in the records, and continues to do so.  What can we do?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY IAN DONALDSON:
Regulatory and accreditation requirements make it clear only objective clinical information relative to an individual patient’s medical condition should be documented in the medical record.  Entering comments in a patient’s medical record that are critical of other individuals – or the hospital itself – is inappropriate and does not advance the care of a patient.  These types of extraneous comments can also create legal risks to the hospital and to all individuals involved in the care of the patient.

A physician who has a complaint or concern regarding the care provided by another member of the health care team should be advised that the medical record is not the proper forum for reporting such issues.  Instead, they should be directed to register those concerns through the appropriate administrative reporting channels.  Most times, providing this education and counseling to the physician is sufficient to resolve the concerns and change their behavior.  If not, the physician should be advised that failure to follow hospital and medical staff policy regarding appropriate medical record entries will be referred for review under the Medical Staff’s Professionalism Policy or Code of Conduct.

If you have a quick question about this, e-mail Ian Donaldson at IDonaldson@hortyspringer.com.