Page 25 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

Accurate and Complete

Accuracy is best demonstrated by providing not only the objective

findings, but also your subjective impressions and conclusions,

refraining from biased opinions. The record should contain a

complete medical history, X-rays and other diagnostic tests or

reports and above all else, your differential diagnosis and plan of
treatment. If your treatment plan deviates from any local

community standard or nationally recognized guidelines,

document your rationale for doing so, especially for cases in which

the medical record might suggest another course was overlooked.

For example, document the rationale for not following the written
recommendation of a consultant. This need not be lengthy, but

should indicate alternatives considered, your medical judgment

and the clinical basis for your decision. Even if you’re wrong, an
3
accurate record that documents why your decisions were

reasonable at the time given the information available to you will

serve as a powerful defense against later accusations of
negligence.

If medications or additional history is not available upon admission

or the patient or family are poor historians, document such along

with your efforts to obtain that information.

You have a nondelegable duty to be aware of all relevant and
available medical information about the patient. Document that

you sought old charts and diagnostics for comparison when

3 https://www.rmf.harvard.edu/Clinician-Resources/Article/2002/Documentation-Dos-and-Donts

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