Page 20 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

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

The record should contain only facts and clinical judgment.

Personal remarks on a patient’s characteristics or character are
not appropriate. Additionally, the medical record should not be

used to criticize other providers or hospitals. Records should be
complete, but this does not mean everything must be written

down. Poorly written voluminous records may actually increase
liability exposure; the key is that the record be objective and

concise. All boxes and checklists should be completed to show
they were reviewed. Any lists which are written should be

complete or have an all‐inclusive statement.

NEVER EVER ALTER A MEDICAL RECORD – Every EHR has an audit
trail and sophisticated techniques have been developed which

enable experts to detect the majority of alteration attempts. If
it is determined that medical records have been altered, it will

not only severely damage the chances of prevailing in a medical
malpractice lawsuit, but the professional liability coverage for

the incident may be at risk. Changes in the medical record,
including additional notes, after receipt of a claim or lawsuit

should not be made without consulting an SVMIC attorney.

Dictation

The successful defense of a malpractice claim or lawsuit

correlates closely with the completeness and legibility of a
physician’s medical records. SVMIC has found that physicians

are more thorough in the documentation of medical care when
they dictate their records as opposed to hand written records.

Moreover, dictated records look more professional to a jury.
Although they may initially increase costs, dictated records

often result in a higher degree of productivity and efficiency.
Because dictation takes less time, physicians may also be able

to see more patients. Ideally, physicians should dictate in the

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