Page 9 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

PART ONE

Introduction

Documentation requirements may vary by specialty, patient
population, setting or level of care, treatment and services being

provided. Therefore, it is important that you are apprised of the

specific requirements pertaining to your particular situation.

It is well-known that a complete and accurate medical record will

help foster quality of care. Most importantly, it is the footprint that
guides the course of the patient’s medical care and provides

needed information to subsequent healthcare providers who

facilitate continuity of care. What might not be as well-known is

that an incomplete or inaccurate medical record can be a factor in

causing patient harm. Although the primary purpose of
documentation is to facilitate good communication among

providers and continuity of care, when there are poor outcomes,

documentation often becomes the main focus of litigation.

Therefore, it is no surprise that the quality of physician

documentation not only spells the difference between a defensible
malpractice case and an indefensible one, but often determines

whether the suit gets filed in the first place. That’s because a

malpractice case typically begins with a plaintiff attorney’s review

of the medical record. If the attorney finds thorough

documentation of medical care falling within acceptable
standards, there is very little chance that the investigation will go

any further.

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