Page 60 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

A jury in a medical malpractice action will equate poor
documentation with inadequate patient care. It is recommended

that only standard abbreviations be used so entries are easily
understood. In addition to being legible and clear, the accuracy

of the medical record is vital.

The record should contain only facts and clinical judgment.

Personal remarks on a patient’s characteristics or character

are not appropriate. Additionally, the medical record should
not be used to criticize other providers or hospitals. Records
should be complete, but this does not mean everything

must be included in the record. Poorly documented or even

voluminous records may increase liability exposure. The key
to successful documentation in the medical record is that the
record be objective and concise. All boxes and checklists should

be completed to show they were reviewed. Any lists should

be complete or have an all‐inclusive statement. Once all the
facts have been recorded accurately and the documentation is
completed within a timely manner after the patient encounter,

the risk of liability exposure will dwindle.

Systems

The third category of risk issues identified in obstetrics closed
claims is systems issues. Systems issues were found in 27

percent of the closed obstetrical and gynecological claims.
Effective systems and processes help reduce adverse events

and claims by decreasing reliance on memory or informal
mechanisms alone. When we refer to systems issues, we

are referring to processes or workflow throughout the office,

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