Self-Serving Notes: What are They?
I recently had someone ask me to explain a self-serving note. She had heard the word thrown around by an
attorney relative to a medical malpractice case, but was too nervous to ask the attorney what a self-serving note really was. A self-serving note is just as it sounds. Chances are if you read something in a medical record that appears as if the writer swooped down from the sky like a super-hero wearing a cape and a Big "S" on their chest to save the day, it was probably a self-serving note.
I am sure you have heard the old cliche, "If it sounds too good to be true- it usually is!" The same goes for a self-serving note.
Self-serving notes will always appear to be appropriate, because they have been meticulously drafted after a catostrophic occrrence. Instead of presenting the facts as they occurred, the information within the note will actually be "too perfect."
As a legal nurse consultant, I can tell you that we can spot those immediately within the medical records of a medical malpractice case. If a procedure goes terribly wrong but the note written by the physician or nurse appears as if every single intervention was done perfectly then it was probably self-serving documentation.
It seems to be human nature to want to cover your tracks in the face of catastrophe. Afterall, the general rule within the medical community has always been if it was not documented it was not done. However, as a legal nurse consultant I see things much differently. I guess it is my skepticism that allows me to have this different perspective - Just because it was documented, does not mean it was actually done. It is my job to piece together the facts, and if the facts don't fit the documentation there is probably self-serving activity involved.
As a medical provider you don't have to be guilty of any negligence or medical malpractice to be guilty of self-serving documentation. Elaborate narratives embelished to create intriguing stories are usually self-serving after an unusual event has occurred. This will look extremely suspicious to a legal nurse consultant who will investigate the matter further, and probably have you answering questions regarding that story at deposition. So, a word of advice for documentation after a catastrophic event, just stick with facts, don't embelish and don't pretend to know something that you don't.
attorney relative to a medical malpractice case, but was too nervous to ask the attorney what a self-serving note really was. A self-serving note is just as it sounds. Chances are if you read something in a medical record that appears as if the writer swooped down from the sky like a super-hero wearing a cape and a Big "S" on their chest to save the day, it was probably a self-serving note.I am sure you have heard the old cliche, "If it sounds too good to be true- it usually is!" The same goes for a self-serving note.
Self-serving notes will always appear to be appropriate, because they have been meticulously drafted after a catostrophic occrrence. Instead of presenting the facts as they occurred, the information within the note will actually be "too perfect."
As a legal nurse consultant, I can tell you that we can spot those immediately within the medical records of a medical malpractice case. If a procedure goes terribly wrong but the note written by the physician or nurse appears as if every single intervention was done perfectly then it was probably self-serving documentation.
It seems to be human nature to want to cover your tracks in the face of catastrophe. Afterall, the general rule within the medical community has always been if it was not documented it was not done. However, as a legal nurse consultant I see things much differently. I guess it is my skepticism that allows me to have this different perspective - Just because it was documented, does not mean it was actually done. It is my job to piece together the facts, and if the facts don't fit the documentation there is probably self-serving activity involved.
As a medical provider you don't have to be guilty of any negligence or medical malpractice to be guilty of self-serving documentation. Elaborate narratives embelished to create intriguing stories are usually self-serving after an unusual event has occurred. This will look extremely suspicious to a legal nurse consultant who will investigate the matter further, and probably have you answering questions regarding that story at deposition. So, a word of advice for documentation after a catastrophic event, just stick with facts, don't embelish and don't pretend to know something that you don't.
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