Page 37 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

during every step of the treatment will portray the competence and

compassion of the physician. Communications between the

primary care physician, surgeon and other specialists that are
timely and thorough, again with appropriate contemporaneous

documentation, are factors to enable the jury to fill in the gaps if

your care is challenged. While good documentation can provide

the necessary support to defend a physician at trial, it can often

prevent a claim or lawsuit from being asserted in the first place.

Conversely, erroneous or incomplete documentation can often be
the linchpin that supports the plaintiff’s theory of liability. A

complete, legible and organized medical record ensures that

subsequent caregivers have the objective information necessary to

provide continuity of care.

Regardless of the type of medical recordkeeping system that is

used, paper or electronic, your notes should always be able to

describe the story of a patient’s clinical picture in as much detail as

is required to accurately re-tell the story. The story should describe

in sufficient detail what took place, what the thought processes
were and what instructions were given to the patient. The records

must be legible, and the accuracy of the medical record must be

unquestionable. The objectivity of the medical record is of utmost

importance in order to demonstrate that the care was unbiased

and professional. Remember that the medical record is a legal
document, and the documentation within the record will reflect the

approach you and your staff have in providing care for your

patients.

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