Let's not worry about the patient for a few minutes. Let's look at how any "vulnerability of vocabulary" or "window of doubt" in your dictated reports and chart notes might jeopardize your future as a doctor.
In each of the situations described in this chapter, try reacting to the material you are asked to examine as if you were viewing it through three different lenses.
- Posing as the ordinary man on the street, ask yourself if you can understand the material presented to you.
- Assuming your current status as a healthcare provider (a physician who might be a defendant or an expert witness), ask yourself if you can clearly understand the material presented to you.
- Pretending that you are a celebrity attorney like Johnnie Cochran or Alan Dershowitz, ask yourself if there is even the slightest doubt as to the meaning of any detail contained within the material presented to you.
Remember that lawyers are always looking for a chink in someone's armor. The tiniest imperfection can lead an aggressive attorney to an area of weakness that can be magnified and re-examined ad nauseam until it begins to impeach someone's credibility.
Here are some typical problems with patient documentation which a skillful attorney can manipulate to his client's advantage.
Next: Penmanship
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