Page 16 - Risk Reduction Series - Documentation Essentials (Part One)
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SVMIC Risk Reduction Series: Documentation Essentials
☐ Documents that do not constitute the official medical
record should be kept separate from the medical record
and restricted from disclosure. Examples include incident
reports, peer review documents, privileged documents,
and correspondence with SVMIC.
☐ Original medical records should not be removed from the
office.
☐ Use only standard abbreviations so entries are not
misunderstood.
☐ Accuracy is vital. A misplaced decimal point or inadvertent
use of a wrong term has precipitated medical disaster.
☐ The record should contain only facts and clinical judgment.
Remarks on a patient’s personal characteristics are not
appropriate. Additionally, the medical record should not be
used to criticize other providers or hospitals.
☐ NEVER ALTER A MEDICAL RECORD! Sophisticated
techniques have been developed which enable experts to
detect alteration attempts. If it is determined that medical
records have been altered, it will not only all but destroy
chances of prevailing in a medical malpractice lawsuit, but
also professional liability coverage for the incident may be
at risk.
☐ Never make a change in the record (including additional
notes) after notice of a claim or lawsuit has been received
without consulting an SVMIC Claims Attorney or assigned
defense counsel. RISK MANAGEMENT ACTIVITY OR
CONVERSATIONS WITH A PERSONAL ATTORNEY,
DEFENSE ATTORNEY, OR SVMIC CLAIMS ATTORNEY
SHOULD NOT BE DOCUMENTED IN THE RECORD.
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