Page 14 - Part Two Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
records and peer review documents should also be kept out of the
medical record. Most communications with your attorney are
legally privileged and, as such, are not subject to discovery. These
communications should be kept separate from the patient’s chart,
thereby eliminating the possibility of their being photocopied or
provided to the opposing party without a court order specifically
compelling their production.
Unique to Paper Charts
There should be a separate record for each patient.
All papers should be permanently affixed in the record.
Patient identification should be on the front and back of
every page containing patient information.
For paper records in which handwritten notations or
signatures are found, maintain a signature log or card that
identifies the name and title associated with initials used in
the medical record.
Legibility is a must! Careful diagnosis and a good treatment
plan are useless if the written orders are illegible. Remember
that a jury in a medical malpractice action will equate hurried
and sloppy documentation with sloppy care.
Documentation – Pitfalls in Electronic
Health Records
An analysis of medical malpractice cases found that incorrect
information (e.g., faulty data entry) was the top EHR-related
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