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Sidebar - What Your Signature Says · Statutes & Stethoscopes | Trial Lessons for Medical Injury Lawyers

• 0:03
  SPEAKER_00: This is that.
• 0:06
  SPEAKER_00: I'm Tracy Libertory.
• 0:08
  SPEAKER_00: Every episode I take one place where medicine and the courtroom collide and break down what actually works.
• 0:14
  SPEAKER_00: You're a clinician who wants this work, or an attorney who needs an expert who can hold up.
• 0:19
  SPEAKER_00: You're in the right place.
• 0:20
  SPEAKER_00: Let's get into it.
• 0:25
  SPEAKER_00: In the last sidebar, we talked about when a supervising physician is on the line for a physician assistance care.
• 0:32
  SPEAKER_00: Today is the question the hospitalist really wanted answered.
• 0:36
  SPEAKER_00: When I sign off on a PA's chart, what the heck should I write?
• 0:41
  SPEAKER_00: And is it better to say more or to say less?
• 0:44
  SPEAKER_00: You know, as in I spoke with the PA or we went over the case, we discussed the medications and the plan, or is it better to say as little as possible?
• 0:52
  SPEAKER_00: Something like I reviewed the note and I approve of the plan.
• 0:54
  SPEAKER_00: And it's a fair question, and I understand the instinct behind it.
• 0:58
  SPEAKER_00: If I say less, maybe I'm less involved.
• 1:00
  SPEAKER_00: If I say more, maybe I look more careful.
• 1:02
  SPEAKER_00: But both of those instincts miss the point.
• 1:05
  SPEAKER_00: The safest signature isn't the longest one or the shortest one.
• 1:09
  SPEAKER_00: It's the true one.
• 1:10
  SPEAKER_00: So let's take the short version first.
• 1:13
  SPEAKER_00: Saying less does not take you off the hook.
• 1:16
  SPEAKER_00: In Pennsylvania, the Medical Practice Act already makes the supervising physician responsible for the medical services the PA renders.
• 1:24
  SPEAKER_00: That responsibility comes from the relationship and the written agreement, not from how many words you put on the chart.
• 1:31
  SPEAKER_00: A two-word cosignature is still your signature.
• 1:35
  SPEAKER_00: It still tells a jury that you reviewed the note.
• 1:37
  SPEAKER_00: And if the plan was wrong, approve means you approved it.
• 1:42
  SPEAKER_00: Now the long version.
• 1:44
  SPEAKER_00: Saying more than you did is worse.
• 1:47
  SPEAKER_00: Remember Oka versus Avila from last time.
• 1:50
  SPEAKER_00: The attending co-signed a PA's emergency department chart with this line: I agree with the assessment and care plan and confirm the diagnosis.
• 1:59
  SPEAKER_00: Then he testified he never saw the patient, and there was no evidence he looked at the x-ray.
• 2:04
  SPEAKER_00: So the chart said one thing and his testimony said another.
• 2:07
  SPEAKER_00: That gap is exactly what kept him in the case.
• 2:11
  SPEAKER_00: And here's the part I want every physician to hear.
• 2:14
  SPEAKER_00: Writing that you discussed the case with the PA when you didn't isn't just risky.
• 2:20
  SPEAKER_00: It's documenting something that didn't happen.
• 2:23
  SPEAKER_00: That's the same problem we'll talk about in the next sidebar.
• 2:27
  SPEAKER_00: Charting care that was never given.
• 2:29
  SPEAKER_00: Once a jury catches one false statement in your note, they stop trusting the rest of it, including the parts that were true.
• 2:36
  SPEAKER_00: So, what does a good cosignature look like?
• 2:40
  SPEAKER_00: It says what you actually did.
• 2:43
  SPEAKER_00: Nothing more and nothing less.
• 2:45
  SPEAKER_00: And it says it specifically.
• 2:47
  SPEAKER_00: If you only reviewed the chart, say that.
• 2:50
  SPEAKER_00: Something like chart reviewed with this date and time.
• 2:53
  SPEAKER_00: I did not see or examine the patient.
• 2:55
  SPEAKER_00: I agree with the plan as documented.
• 2:57
  SPEAKER_00: If you talked with the PA, say when and about what.
• 3:00
  SPEAKER_00: Discussed with the PA at 215.
• 3:02
  SPEAKER_00: Reviewed the labs and the chest x-ray.
• 3:04
  SPEAKER_00: Agree with the starting antibiotics, added blood cultures.
• 3:08
  SPEAKER_00: If you saw the patient, say what you found yourself, not what the PA found.
• 3:12
  SPEAKER_00: Your own exam in your own words.
• 3:15
  SPEAKER_00: And if you disagree with something, say so and say what you did about it.
• 3:20
  SPEAKER_00: Spoke with the PA, changed the dose, notified the nurse.
• 3:24
  SPEAKER_00: A cosignature that disagrees and then shows action is one of the strongest things a supervising physician can have in a chart.
• 3:31
  SPEAKER_00: A co-signature that disagrees and then shows nothing is one of the worst.
• 3:36
  SPEAKER_00: Now, let's talk about the template problem because I think this is where most physicians get into trouble without knowing it.
• 3:43
  SPEAKER_00: A lot of electronic health record systems insert at testation language automatically.
• 3:48
  SPEAKER_00: You click sign, and the system adds a sentence like, I've personally seen and examined the patient and agree with the findings and plan.
• 3:56
  SPEAKER_00: Many physicians have never actually read the sentence their system inserts under their name.
• 4:02
  SPEAKER_00: If that sentence isn't true for this patient, it's your signature on a statement that isn't true.
• 4:09
  SPEAKER_00: Read it.
• 4:10
  SPEAKER_00: If it doesn't fit, change it or ask your facility to give you an option that does.
• 4:16
  SPEAKER_00: There's a billing side to this too.
• 4:18
  SPEAKER_00: In many systems, the attestation is part of what supports how the visit gets billed.
• 4:24
  SPEAKER_00: If a note is billed as if the physician did more than he did, the overstated attestation becomes a billing compliance problem on top of a liability problem.
• 4:34
  SPEAKER_00: Your compliance department can tell you what your facilities rules are.
• 4:38
  SPEAKER_00: The principle is the same either way.
• 4:41
  SPEAKER_00: The note has to match what happened.
• 4:44
  SPEAKER_00: Timing matters as well.
• 4:46
  SPEAKER_00: If your written agreement says you'll countersign within a certain period, and the audit trail shows that you signed a stack of charts weeks later in one sitting, that tells a story about how much supervision was really happening.
• 5:00
  SPEAKER_00: Remember, in Pennsylvania, a PA in the first 12 months after graduation or in a new specialty needs a hundred percent of charts countersigned within 10 days.
• 5:12
  SPEAKER_00: Know which of your PAs fall into that window.
• 5:15
  SPEAKER_00: A few practical things for our hospitalist and for any physician in his position.
• 5:21
  SPEAKER_00: Read the written agreement you signed.
• 5:23
  SPEAKER_00: Know what it says about supervision and countersignature, because that's the standard you'll be held to.
• 5:29
  SPEAKER_00: If you're being asked to supervise more than you can realistically can't carry, put that concern in writing to your department and call your own malpractice carrier and ask a plain question.
• 5:43
  SPEAKER_00: Does my policy cover claims based on my supervision of PAs?
• 5:47
  SPEAKER_00: Better to know now.
• 5:49
  SPEAKER_00: For our experts listening, when you review a supervising physician's conduct, put the cosignature next to everything else.
• 5:57
  SPEAKER_00: What did it say?
• 5:58
  SPEAKER_00: When was it signed?
• 5:59
  SPEAKER_00: Does it match the audit trail, the physician's testimony, and the rest of the chart?
• 6:04
  SPEAKER_00: A cosignature that matches the record is just a signature.
• 6:08
  SPEAKER_00: A cosignature that claims more than the record supports is where the case is.
• 6:13
  SPEAKER_00: Here's today's takeaway.
• 6:15
  SPEAKER_00: Don't write less to protect yourself, and don't write more to look careful.
• 6:19
  SPEAKER_00: Write exactly what you did, when you did it, and what you decided.
• 6:25
  SPEAKER_00: Your signature is a statement of fact and it will be read back to you.
• 6:30
  SPEAKER_00: This is educational information, not legal advice.
• 6:33
  SPEAKER_00: Supervision, countersignature, and billing rules vary by state, payer, and facility, so check with the retaining attorney and your facilities compliance team.
• 6:43
  SPEAKER_00: This episode of Statutes and Steph Discoveries.
• 6:46
  SPEAKER_00: If it was useful, follow the show so the next one finds you.
• 6:50
  SPEAKER_00: And if you're a clinician who wants to do this work properly, start with the Expert Report Starter Club at Nationalexpertacademy.com.
• 6:57
  SPEAKER_00: I'm Tracy Libratori.
• 6:59
  SPEAKER_00: I'll see you on the next episode.