Page 32 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

physicians assume that “inadvertent” is synonymous with

“unintentional.” In fact, some dictionaries define it as “heedless,”

“careless,” or “negligent”—words you certainly wouldn’t want used
to describe your care. It is best to stick to a simple, objective

description of what happened and let the facts speak for

themselves.

 Never alter any prior documentation or insert backdated

information.

 Never use the record to speculate about the causation of the

adverse outcome or express dissatisfaction about other

caregivers, equipment or administrative processes.

 Never put a copy of an “Incident Report” or include

documentation of corrective actions taken (i.e. an employee

disciplinary action document) in the medical record.

 Record only the care and treatment of the patient given

during the event.

 Contact an SVMIC Claims Attorney. SVMIC encourages the

reporting of any matter that concerns you or your practice
related to a potential malpractice issue.

Avoid Using Disclaimers for Dictation,

Voice Recognition Software or EMRs

Have you ever opened up a medical record and seen something

out of place? Immediately you realize there’s been an overlooked

mistake in the medical record, and it takes a couple of reviews to
figure out the intended message. Below are some humorous

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