Including Supplemental Documents


“We have a surgical case for external review. In addition to the medical record, we have documentation from interviews of the physicians and nurses involved in the care, as well as from the completed internal physician peer review.  Should we include these additional documents with the record for external peer review?”



The most significant argument against inclusion of such documents is that they can stand to bias the reviewer. Recorded interviews, accounts of what transpired, minutes of committee discussions or rebuttals to internal review often reflect feelings, emotions, personality and opinions that threaten objectivity. If a complete and fair assessment can be made based on the medical record alone, that is usually the best course.

While it is usually inadvisable to include documents to supplement the medical record, there are certainly exceptions. If the additional documents provide information deemed critical to the assessment that can’t otherwise be found in the medical record and the importance of that information outweighs the potential negative impact of the bias it might create, then it should be included. But this decision warrants careful thought.

We advise our clients, especially for cases of concern, to always proceed as if progressing toward a fair hearing or court of law. While such proceedings may be unlikely, taking every step as if it will be closely scrutinized by conflicting parties helps to keep the process on a defensible track. It is not uncommon for peer review outcomes to be challenged on the basis of bias or conflict of interest. Therefore, neutralizing this potential from the outset is crucial. Yet even more important than these strategic considerations, managing bias and conflict of interest is simply the right thing to do. For peer review to be credible and trusted, and for peer review to reach its potential, objectivity is essential.

Another common problem with inclusion of supplemental documentation is that it can contradict not only the medical record, but also contain contradictory accounts of the same event. Putting the burden on the reviewer to determine whose account is most credible or which facts are correct is unreasonable in most cases. If there are conflicting accounts of the care provided, these conflicts might best be resolved through an internal investigation prior to peer review.

If they add nothing, leave the supplemental documents out. If they are emotionally charged, provide conflicting information, contradict the medical record or otherwise have the potential to interfere with the integrity of the peer review, weigh the benefits against the potential costs and proceed with extreme caution. After careful thought, if there is still doubt, leave the supplemental documents out.