Page 13 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

• Self-serving comments and additions to the record made

after a potential claim has been made

There are many factors that contribute to poor documentation
including time pressures, unfamiliarity with EHR systems or

protocols, compliance concerns, and hybrid charting using a
mix of paper and EHR. Before delving into case studies that

highlight a particular documentation issue, let’s review tips from
a medical malpractice trial consultant about the importance of

documentation to a jury.

In her article written for the SVMIC Sentinel, “Addressing

Juror Expectations in Everyday Practice: MEDIC”, Jill Huntley
Taylor, Ph.D., discusses how crucial documentation is to a

jury’s evaluation of a case. She states, “As a trial consultant,
I am involved in conducting mock trials in all types of cases,

including medical malpractice cases. In each case, I am looking
for the problems and opportunities to help the team develop the

best strategies for the case with the goal of prevailing at trial.
In addition to the case-specific work, I am always listening to

the mock jurors and paying careful attention to trends based
on what they say about the case and the parties. I pay close

attention to what upsets mock jurors, which often centers
on how a patient was treated, or how that treatment was

communicated to the patient and in the medical record.” She
goes on further to explain that jurors look for evidence of both

communication and medical care in the medical documentation.
Time and time again, documentation is raised as an issue in

medical malpractice cases. Jurors often believe that if it’s not in
the record, it did not happen. They have very high expectations

for medical documentation and rely heavily in their deliberations
on what was documented contemporaneously.

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