Page 16 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

appropriate. Additionally, the medical record should not be

used to criticize other providers or hospitals.

 NEVER ALTER A MEDICAL RECORD! Sophisticated

techniques have been developed which enable experts to

detect alteration attempts. If it is determined that medical

records have been altered, it will not only all but destroy
chances of prevailing in a medical malpractice lawsuit, but

also professional liability coverage for the incident may be at

risk.

 Never make a change in the record (including additional

notes) after notice of a claim or lawsuit has been received

without consulting an SVMIC Claims Attorney, or assigned

defense counsel. RISK MANAGEMENT ACTIVITY OR
CONVERSATIONS WITH A PERSONAL ATTORNEY, DEFENSE

ATTORNEY OR SVMIC CLAIMS ATTORNEY SHOULD NOT BE

DOCUMENTED IN THE RECORD.

 A one-screen summary which includes active problems,

medications, allergies and progress notes, as well as an

organized view of test results or progress notes should be

available.

 Completed office notes should be electronically signed and

locked so they cannot be modified or revised.

 Discontinued medications should be easily identified in the

EHR and should not “disappear” once discontinued.

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