Page 16 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

Medical Records

It is impossible to overemphasize the importance of maintaining
complete, legible medical records. A quality medical record

not only serves as evidence of all pertinent facts related to the
diagnosis and treatment of a patient, but also fosters effective

communication among members of the healthcare team
and promotes effective management of patient care. Good

documentation is one of the most important patient care and
medical risk management skills a physician can develop. The

soundness of the medical record can be judged by asking
whether or not another physician could provide immediate

and appropriate medical care in your absence with only your
medical record for assistance.

In the event of a medical malpractice lawsuit, the medical

record becomes a legal document and may be one of the most
powerful, objective, and persuasive pieces of evidence proving

the physician met the applicable standard of care. It should
also be emphasized that a well‐documented, legible medical

record may actually prevent the filing of a lawsuit. One of the
first things an experienced malpractice attorney considering a

malpractice case will do is review the medical record looking
for evidence to support claims of liability. If the attorney finds

a clear, complete, and accurate record to the extent that even
creative interpretation will not support a finding of liability, the

attorney may decline to proceed further. Keeping accurate
records and consulting them prior to beginning or continuing

treatment is integral to good medical practice – failure to do
so results in medical malpractice cases being more difficult to

defend and may result in a plaintiff verdict.

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