Page 19 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

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

Each encounter with a patient must be documented

appropriately. All treatment given, subjective comments or
complaints, response to treatment, and patient progress should

be clearly explained in the medical record. As a guideline for
defining the levels and components for coordination of care,

the examination/assessment should include information that is
obtained, gathered, and documented by the physician, based on

clinical judgment and the nature of the presenting problem(s).

Accuracy, Completeness, and Legibility

Records should be prepared with treatment as
contemporaneously as possible in order to avoid confusion

and help ensure validity. Entries should appear in chronological
order; each entry should be initialed and dated. The physician

should initial and date all lab, x‐ray, and consultant reports after
reviewing.

Legibility and clarity are a must, and it is helpful to use a
consistent format such as SOAP. Careful diagnosis and a good

treatment plan are useless if the written orders are illegible or
unclear. A jury in a medical malpractice action will equate poor

documentation with inadequate patient care. It is recommended
that only standard abbreviations be used so entries are easily

understood.

In addition to being legible and clear, the accuracy of the
medical record is vital. A misplaced decimal point or the

inadvertent use of a wrong term has precipitated medical
disaster. Physicians should be meticulous in charting drug

names, doses, and regimens.

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