Inadequate nursing home notes can cause trouble for physicians and patients

Many physicians who make informative notes in their private offices, the ER, and on acute care wards struggle to do as well in nursing homes where the circumstances are challenging. The office, the ER and the ward are scheduled into the work week. Often residents of long-term care (LTC) facilities are seen by physicians on short notice, during the noon hour, or on the way home from work. While patient assessment, writing orders, and (ideally) calling a family member are given appropriate priority, the note is too-often cryptic, and sometimes there is no note at all.

Most residents of LTC facilities will die there. Every call has the potential to presage a terminal illness or major set-back. Grief at the death or significant deterioration of an elderly parent, even if anticipated, may trigger intense emotions and questioning, and potentially a complaint to the College, the facility, or the health authority. 

The Inquiry Committee recently concluded its investigation of allegations of inadequate care of a 97-year-old woman with criticism of the family physician, despite apparent regular attendances. The physician had made no record of his assessments and the care provided. The Inquiry Committee determined that the patient record was of no assistance to the physician in defending his actions and had no option but to be critical. This is a common finding with nursing home complaints. Care facility staff and physician colleagues are often challenged to provide optimal care because other physicians have failed to document what they have found and done. With these observations in mind, physicians are reminded to give attention to the quality of their nursing home records.