Hitting a Nerve

Nota bene: Don’t change a note


 

A man I saw earlier this year called my office recently. He’d read my note, and after discussing it with his attorney, wanted me to make changes. He said that the way I’d described his symptoms would be damaging to a legal action he was involved in, and so he wanted it reworded.

Dr. Allan M. Block, a neurologist is Scottsdale, Ariz.

Dr. Allan M. Block

Obviously, I said “no.” I’m not a fiction writer. My notes are what people tell me happened. I don’t make them up.

He wasn’t happy about this, and a few days later I got a request to send his records to another neurologist, which I gladly did.

In this business a large measure of what we do is based on the patient’s symptoms. what they report to us, and how they describe it. When I put their story into a written note, my goal is to be as accurate to what they told me as possible. I’m not here to embellish, disparage, or minimize their history.

A chart, as was drilled into me throughout training, is a legal document. Once I’ve signed off on a note it can’t be changed. To do so is to look bad at the very least and open yourself up to malpractice and legal charges at worst.

This isn’t to say errors can’t be modified. I’m far from perfect. Sometimes I might misunderstand something a patient tells me, or get information crossed up. When that happens there’s nothing wrong with writing an addendum, clarifying or correcting what my earlier note said – but not changing the original note.

I asked the unhappy patient to write down what he thought was incorrect, and I’d be willing to include that in his chart. He wasn’t willing to do that, and there was no way I would ever change a note. I tried to politely explain the reasons why, but he wasn’t listening.

So I lost him as a patient. After 23 years of practice, that doesn’t bother me. I learned a long time ago that I can’t please everyone, nor can I be everyone’s doctor. Saying “no” is just as important as saying “yes,” though at times more difficult.

This time, though, the answer was pretty obvious, and will be the same next time I get the same request from a patient.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

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