Page 34 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

From a patient-care standpoint, the disclaimer may

unintentionally send the message to subsequent providers that
the records cannot be relied upon.

Some key points to remember about authenticating entries in

the medical record:

• All notes and medical record entries must be reviewed for

accuracy and consistency and properly authenticated by
the physician.

» Signing indicates that the record has been
authenticated as accurate.

» Using a “signed but not read” stamp would not

excuse you from liability if the inaccurate entries are
relied upon in treating the patient.

• Electronic signatures are allowed, but in no way do they
act as a substitute for your personal review of the record.

• Turnaround time for the dictation or electronic entries
to be posted in the record should not exceed 48 hours,

although 24 hours is ideal. Delays past 48 hours may cause
problems with patients who should be followed closely.

With such patients, physicians should create written notes
and keep them until the transcription is in the record.

Conclusion

The importance of complete, accurate, and contemporaneous
documentation cannot be overstated. Poor documentation

is a primary factor negatively affecting the defensibility of a

malpractice claim. Taking a critical look at your documentation

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