Page 14 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Because documentation is evidence, what is not documented is as

important as what is documented. Just as jurors have a difficult

time believing something happened if it is not documented,
anything that is documented can take on a life of its own at trial.

Such documented evidence can be put up in front of a jury for

their study and scrutiny. This is especially troublesome in cases of

inappropriate documentation. Noting opinions in the medical

records, particularly unflattering opinions of patients, staff, or other
doctors, is likely to be problematic at trial. Thoughtful and

thorough documentation can greatly help in the defense of a case.

Factual and objective documentation of the medical care is key.

Now that we have outlined why this course in documentation

fundamentals is meaningful to both patient care and jury

expectations, let’s start with a review the laundry list of general
guidelines.

General Documentation Guidelines

 Records should be organized thoughtfully and efficiently so

that the medical and office staff can quickly locate

information in any given record (i.e. grouping all progress

notes together, all lab results together, consults together,

etc.).

 Records should be complete. This does not mean

documenting everything. Poorly written, voluminous records
may actually increase liability exposure. The key is to be

objective and concise.

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