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This case illustrates the consequences of failing to fulfill one of the primary responsibilities of any physician: complete and timely documentation. While in any examination of a liability case it can be tempting to concentrate on the appropriateness of care, such a discussion becomes impossible without an adequate treatment record. Since it is obvious that incomplete documentation was a key factor in the assignment of liability in this case, a discussion of how documentation affects both care and liability management is valuable.

One of the principle purposes of documentation is facilitating continuity of care. Medical liability aside, inadequate record keeping made it impossible for this physician to provide even effective treatment. An example taken from this case is the management of hypertension, which requires that the physician develop an individualized understanding of the patient and the status of the disease process. It is unrealistic to imagine that the physician remembered the patient's vital signs from the previous visit, much less the trends he should have observed during the patient's 30 visits spanning a period of four years.

Documentation and proper care both require time, a commodity often in short supply in a busy practice. Given the importance of the medical record a system that ensures its accuracy and completeness is a priority. Simple practices such as patients filling out their own review of systems or the nurse documenting vital signs can serve to both save time and direct the physician's course of treatment. While handwritten notes are time consuming and often illegible there are viable alternatives, like electronic medical records or dictation, which facilitate brief and precise documentation. These, and myriad other approaches can help provide improved documentation, but it remains the responsibility of the physician to select and implement their use.

Without documentation this case became nothing more than a question of whether the jury believed the physician's or the patient's version of the events. The physician's course of treatment may or may not have reached a minimum standard of care, but this question is impossible to resolve because of his failure to keep proper records. The remedy for this situation is to choose and commit to a system of timely and accurate documentation, possibly facilitated by delegating some of this process to both the patient and office staff. Even with limited time the medical record is one of the pillars of both proper care and risk management.

Given the current view that primary care physicians are directors and coordinators of care and subsequent unrealistic patient expectations for that care, any failure or delay in evaluation, diagnosis, and treatment can be grounds for litigation. Thus, implementation of several proactive techniques can insure the achievement of standard of care and reduction of risk and liability.

First and foremost, the outcome of this claim demonstrates the absolute necessity of proper documentation. Did this physician fail to document the two previous references to a mole, or did this patient fabricate the two previous references? Give over two dozen omissions of vital signs in this hypertensive patient's medical record, how difficult do you think it would have been for a plaintiff's attorney to persuade a jury that this physician clearly did not document two earlier references to this mole? Although some feel that documentation has become a bane of modern medicine, always remember that proper documentation is protection. It is protection from the mind's tendency to forget and distort the past, and it is protection from the 20/20 hindsight of expert witnesses.

Furthermore, it behooves all physicians to act quickly if a medical decision is out of their realm of expertise. In these situations quick referrals to experts can avoid potential conflicts such as the one in this claim. This patient would most likely have benefited from an earlier referral to a dermatologist to evaluate his condition. Nevertheless, in a common scenario such as this involving a skin lesion, records such as photographs are as the saying goes "worth a thousand words" and should be kept in a patient's medical record.

Finally, it is vital to assess the health literacy of patients including their understanding of their medical conditions and treatments plans. Implementation of these simple techniques will help guarantee excellent patient care, safety, and confidence.

I am overbooked in clinic today and need to be home by 5:30 to take my son to his soccer tournament. My next patient is Mr. Rogers, one of my regulars. I have been following him for the past year for hypertension. I go into his room and record his vitals in the chart. Just as I expected, his blood pressure is 128/76. He has no symptoms, and just needs refills of his medications. I look through his chart, noticing his blood pressure has been well controlled at all previous visits and he is current on labs. I also notice that three months ago he was concerned about a mole that was changing colors on his left upper arm. I examine Mr. Rogers and measure his mole at 6 mm x 4 mm. At his last visit the size of the mole was recorded at 4 mm x 2 mm. I inform Mr. Rogers that his mole has changed and needs further evaluation. I give him the options of performing a biopsy or referring him to a dermatologist. He says "I am more comfortable with you than a stranger." I am proud that he has confidence in me, but I am running out of time. I scheduled a follow-up appointment for him next week to biopsy the mole.

The next week, I explain to Mr. Rogers that clinically the mole looks like basal cell carcinoma, which is a type of skin cancer that rarely spreads and has a very high cure rate. I also tell him about squamous cell carcinoma, actinic keratosis, and melanoma. I tell him that pathology is necessary for diagnosis.

The pathology reveals melanoma in situ. I call Mr. Rogers and schedule a follow-up appointment to discuss the results. At the appointment, I tell him the lesion was not what I thought originally. I ask him if he would like to know the results and he agrees. I tell him he has melanoma localized to the skin. He says, "that's the bad kind we talked about, right." I tell him it is and I am sorry to be giving him such bad news, but it is still localized to the skin, and it is good that we caught it in such an early stage. I ask him if he needs to call anyone for support or if he needs help telling his wife. He says he is okay. I refer him to a surgeon and his melanoma is removed with negative margins.

Five years later, I see Mr. Rogers at one of his regular clinic visits. I reflect back on how accurate evaluation and documentation prevented Mr. Rogers from having a higher staged melanoma. I recall how busy my clinic was that day and am relieved that I always kept precise documentation and take time to review it. I have the responsibility to be a good physician that spends time to obtain a full health history, documents it properly, educated the patient, and discusses treatment options. By practicing responsible medicine I am practicing defendable medicine.

Allegations of malpractice in this case center on two claims. The first is that from September 2001 to April of 2003 the family physician failed to properly evaluate, test and diagnose the patient's mole according to accepted standards of care. The second allegation is that once the physician did suspect skin cancer he failed to follow the standard of care in deciding to initially treat with antibiotics rather than make an immediate referral to a specialist for further care. The plaintiff contends that either or both of the above actions by the physician may have caused the cancer to progress undiagnosed and untreated resulting in decreased life expectancy.

Regarding the first accusation, the physician claims he first examined the mole in April 2003 when first noted in the medical record, while the patient claims it was pointed out in September of 2001. Assuming the physician is correct, his position is nevertheless greatly weakened by his failure to establish a pattern of regularly recording physical exam findings and plans of care. Knowing the physician only once documented a blood pressure in the chart while treating the patient's hypertension for four years, a jury would be likely to assume that if the physician had examined the mole earlier than 2003, he would similarly have failed to document that. Also of note is that entries found in the chart were often illegible. One of the most important risk management practices for physicians is keeping accurate, thorough, regular and legible records. His lack of doing so was the principle factor leading to the physician's loss. To his credit he made no additions or changes to his charts, which would have further damaged his credibility.

Also at issue is professional competence. If the patient did bring the mole to the physician's attention prior to 2003, it was likely not properly evaluated. Given its large size and ulcerated state, it is reasonable to assume the mole appeared suspicious prior to 2003. If the physician was unsure about the mole he should have referred the patient to a dermatologist. For a 63-year-old man an annual skin exam is reasonable, and had that been performed and well documented prior to 2003 the physician would have had a much stronger defense.

As for not referring the patient immediately to a surgeon in April of 2003, one could argue there was no good reason for delay. If the physician did suspect cancer (as a reasonable physician arguably would) he should have recorded specific plans to diagnose and treat, including the date of a future visit to remove the lesion in office or record of referral to a specialist. Characteristically, the chart was vague, with a plan described only as "excise or hyfercate later."

In an era of increasing litigation, it has become the physician's responsibility to not only treat patients, but to also protect against legal culpability at the same time. In my own experience and from talking to other physicians the two most commonly practiced methods of protecting oneself from being sued are good patient-doctor communication and proper documentation. In this case the physician appears to be at fault with both these principles.

The particular difficulty in this case seems to be in trying to prove that something did not happen, in particular that the physician had not seen the patient's skin lesion until April of 2003. The physician's best argument is that the mole wasn't seen until April, and at that point he then took the appropriate actions. If the physician was to have shown a history of both consistent and thorough documentation of each patient encounter, it becomes more difficult to argue that the physician somehow failed to mention this skin lesion, but was then thorough in every other aspect of his documentation. There are several techniques the physician could have employed to help in this situation. First, the doctor should have made a comment at the end of each note that the patient had the chance to ask all of his questions and that before exiting the patient understood the plan until his next visit. This would have been more evidence that the doctor went out of his way to allow the patient to mention any concerns about the skin lesion. Next, if the doctor would have had his nurse/staff ask the patient what the reason for the office visit was and then documented it in the chart, it would have been more difficult to argue that he actually mentioned his mole during the visit, yet no one wrote it in the chart. Also the doctor could have drawn a picture of the lesion when it was first mentioned noting the location and size of the lesion; if for no other reason than to monitor any change over time, but at the same time to illustrate a start point to visualization and treatment of the mole. Another technique that may have been very helpful would be to have his existing patients undergo a full physical exam every 1-2 years, this would have most likely revealed this skin finding or any other problems that had gone unnoticed by the patient or doctor. With this exam documented in the chart it would provide more evidence of the doctor's overall quality of care.

The other concern is appropriate communication between the two parties. There appears to be confusion about why the doctor was using antibiotics for a possible malignancy. The patient should have been told why he was being given antibiotics and the physician's differential diagnosis. There isn't any reason not to tell the patient if the physician has concerns about malignancy.

Unfortunately, for this physician it didn't matter how well the patient had been treated. With such poor documentation it became impossible to prove the quality of care given, thus leaving this doctor in the powerless position of he said, she said.

In my medical training, I have been taught that "if it isn't written in the chart then it wasn't done." The patient in the case visited the physician 30 times yet there was only one instance of vitals documented. To diagnose hypertension, the minimum is two instances observed over a period of time. While I hope someone took the patient's blood pressure every visit, without it documented, other must assume that it was not performed. In addition, the physician cannot chart the effectiveness of the treatment plan for hypertension without documented blood pressure. This is an unacceptable level of documentation that leaves the physician exposed legally and prevents proper care.

Regarding the mole on the patient's arm that was found later to be a malignant melanoma, the past medical records give the impression that the doctor was sloppy and careless whether or not this was true. As a family physician he was trained and able to treat skin lesions such as this or to refer if the situation is more complex. Based on the fact that the skin lesion was atypical this situation may have been handled correctly from April 2003 onward. When the lesion was unresponsive to antibiotic treatment, he properly referred the patient to the surgeon for excision. Questions arise from the documentation to "excise or hyfercate later." If the lesion needed to be excised, he should have made arrangements to do so. Writing in the chart "reevaluate later" would have been more acceptable if he felt the lesion was likely not skin cancer. This raises the question presented in the case of whether antibiotic treatment was the standard of care for suspected skin cancer. This calls the physician's practice into question in addition to his documentation.

The major problem was whether or not the physician was aware of this skin lesion as of September 2001. If he was aware in 2001 and did nothing, the physician also needs to be referred to the state medical board in addition to the legal proceedings. The physician in question has allowed himself to be set up for disaster. His failure to thoroughly document details from patient visits leaves him at the mercy of the legal system. The case in question comes down to the patient's word against the physician's medical records. Based on past medical records that were reviewed by others, the notes were poorly written, but the physician did practice within the standard of care by ordering appropriate tests, etc. Had the physician properly documented everything from the visits and set a high standard of doing so, this case would have no strength. It is unknown whether or not this lesion was brought to the physician's attention much earlier so the issue that needs to be addressed is the level and quality of charting patient visits. Better documentation is necessary to provide the highest quality of care for other patients and allow the physician to defend himself in future legal situations.

Thirty visits to a primary care doctor, two ineffective antibiotics, one bleeding mole . . . zero documentation of possible skin cancer.

Melanoma is a frustrating disease to diagnose and treat. With appropriate precautions and proper record keeping, however, this type of malignancy can be caught before it spreads. With a personal history of over 10 excisional and shave biopsies, numerous lab reports, two re-excisions, and countless skin checks, I have learned first-hand about the screening process for melanoma. As I read this closed claim study, many alarms went off in my head. The patient is concerned. The mole is changing shape and bleeding. The infected appearance did not improve with antibiotics. But were these alarming symptoms also concerning to the patient's practitioner? We do not know because the physician's thoughts were not documented in detail.

When a person finds out that they have cancer, it is a traumatic experience. It may be one of the most difficult situations in their life. They feel frightened, alone, worried, frustrated, angry, depressed, and, likely overwhelmed.

Understandably, a common question might be, "Was this preventable?"

In this case, we do not know if the patient's cancer would have been avoided if it had been discussed, treated, and followed-up at an earlier stage. The central issue in this case is documentation. The following steps that I would have taken to change the course of this patient's care:

• Asked patient to complete a review of systems form - this would have included the patient's chief complaint and any worrisome symptoms for discussion during the visit
• Taken a picture - digital photography is an inexpensive and easy medium to use which, in this setting, would have given clear understanding of what the lesion looked like on initial presentation and how it changed over time;
• Completed an electronic medical record - checkbox-based entries can quickly document which parts of a history and physical are completed during a problem-focused clinic visit. This EMR could have been used and supplemented with a dictation-based system to record the assessment and plan.
• Distributed handouts on skin cancer signs and symptoms
• Personally called the patient to follow up after the clinic visit
• Hired a physician extender - this person would have assisted with follow-up for this patient's care.
• Organized a meeting - a meeting would allow local doctors to share best practices on how to manage a busy clinic schedule while completing necessary documentation.

Although it is sometimes difficult to find time in a busy practice, documentation of a doctor's actions not only records details of an office visit but, more importantly, provides the treating physician with a plan of action for subsequent visits. It may be debatable whether the suggestions listed above would have made a difference in the patient's outcome. Ultimately, however, we have an obligation to our patients to fully document clinic visits so that we can take their care and our overall profession to a higher level.