Page 55 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

in several locations in the EHR which cannot be edited, it is

nevertheless important to create an addendum to correct the
error.

NEVER EVER ALTER AN ELECTRONIC MEDICAL RECORD.

Every EHR has an audit trail. 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 also be at

risk. Further, medical records alteration can result in a claim
against the provider for fraud or evidence tampering opening

the door to claims of punitive damages and in states that have
a statutory cap on damages, removal of the cap. Changes in

the medical record, including additional notes, after receipt of
a claim or lawsuit should not be made without consulting a

SVMIC attorney.

Medical Records

It is impossible to overemphasize the importance of maintaining

complete, legible medical records. A quality medical record
not only serves as evidence of all pertinent facts related to the

diagnosis and treatment of a patient, but also fosters effective
communication between the healthcare team and promotes

the effective management of patient care. Good documentation
is one of the most important patient care and medical risk

management skills a physician can develop. The soundness
of the medical record can be judged by asking whether

another physician could provide immediate and appropriate
medical care in your absence with only your medical record for

assistance.

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