Documentation dos and don'ts can derail a lawsuit.(Practice Trends)

CABO SAN LUCAS, MEXICO -- What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

"You can't control the labor and delivery. The one thing you can do is control what appears in the medical record," he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness--charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. "Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?" he asked.

Adequate documentation may be less than physicians imagine. Writing "Matter was discussed with patient" is better than saying what you discussed, because you risk leaving something out of the record. Writing "Exam was done" or "Doctor was notified" is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

* Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the urge to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.