Page 36 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Some key points to remember about authenticating entries in the

medical record:

 All notes and medical record entries must be reviewed for
accuracy and consistency and properly authenticated by the

physician.

 Signing indicates that the record has been

authenticated as accurate.

 Using a “signed but not read” stamp would not excuse

you from liability if the inaccurate entries are relied
upon in treating the patient.

 Electronic signatures are allowed, but in no way act as a
substitute for your personal review of the record.

 Turnaround time for the dictation or electronic entries to be
posted in the record should not exceed 48 hours, although

24 hours is ideal. Delays past 48 hours may cause problems

with patients who should be followed closely. With such

patients, physicians should create written notes and keep

them until the transcription is in the record.

Conclusion

The importance of complete, accurate and contemporaneous

documentation cannot be overstated. Poor documentation is a
primary factor negatively affecting the defensibility of a malpractice

claim. In order for the healthcare team to provide good care,

everyone on the team should be writing, typing or dictating clear

and concise notes in a timely fashion. Often meticulous, carefully

documented records demonstrating the care and reasoning

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