Page 34 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

Keep in mind, with many patients using mobile phones, records

of a phone call being placed are easy to retrieve. Although they
do not confirm the conversation, they will give details about the

time and length of the call.

At a minimum, the following types of phone calls need to be
documented in the medical record:

• All phone calls in which test results are reported to
patients, noting if the patient was advised to return or seek

other medical attention

• All phone calls in which the patient is advised to return or

seek other medical attention, including instructions to go to
the emergency room

• All phone calls in which a patient requests medical advice
or prescription refills

Amending the Record

A frequently asked question posed to risk managers is “How do

I make a correction to the medical record?” Fraudulent alteration
of a medical record virtually destroys any chance of successfully

defending a medical malpractice claim, even if the medicine
practiced was well within the standard of care. Juries generally

give physicians the benefit of the doubt when it comes to issues
of “medical judgment” but will not forgive any appearance of

tampering, misrepresentation, or cover-up. The consequences
of fraudulent alterations are serious enough that most medical

liability policies, including SVMIC’s, make it grounds for denying
coverage. Although insurers and risk managers constantly

remind physicians of this, we continue to see alterations
sabotage our efforts to defend medical malpractice lawsuits.

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