Page 26 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

in which the medical record might suggest another course

was overlooked. For example, document the rationale for not
following the written recommendation of a consultant. This need

not be lengthy, but should indicate alternatives considered, your
medical judgment, and the clinical basis for your decision. Even
3
if you’re wrong, an accurate record that documents why your
decisions were reasonable at the time given the information

available to you will serve as a powerful defense against later
accusations of negligence.

If medications or additional history is not available upon

admission or the patient or family are poor historians, document
such along with your efforts to obtain that information.

You have a non-delegable duty to be aware of all relevant and
available medical information about the patient. Document that

you sought old charts and diagnostics for comparison when
applicable. Note the actual chart dates reviewed rather than

simply stating that you “reviewed the old chart” .

Ensure Quality Documentation

Often, in a review of medical malpractice claims, key
deficiencies are identified, including a lack of documentation

of clinical findings, clinical rationale, and informed consent.
The quality of documentation also influences the jury if you

find yourself defending your record. As we learned earlier from
Jury Consultant Jill Huntley Taylor, Ph.D, poor documentation

may equal poor quality care in the eyes of the jury. It is
recommended that at least quarterly, you personally assess the

quality of documentation with routine audits of medical records.

3 https://www.rmf.harvard.edu/Clinician-Resources/Article/2002/Documentation-Dos-and-
Donts

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