Page 35 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

practices and making simple changes to improve them will
result in better patient care and reduce the risk of a claim being

asserted in the first place. In order for the healthcare team to
provide good care, everyone on the team should be writing,

typing, or dictating clear and concise notes in a timely fashion.
Often meticulous, carefully documented records demonstrating

the care and reasoning during every step of the treatment will
portray the competence and compassion of the physician.

Communications between the primary care physician, surgeon,
and other specialists that are timely and thorough, again with

appropriate contemporaneous documentation, are factors to
enable the jury to fill in the gaps if your care is challenged.

Good documentation can provide the necessary support to
defend a physician at trial. Conversely, erroneous or incomplete

documentation can often be the linchpin that supports the
plaintiff’s theory of liability. A complete, legible, and organized

medical record ensures that subsequent caregivers have the
objective information necessary to provide continuity of care.

Regardless of the type of medical record-keeping system that
is used, paper or electronic, your notes should always be able

to describe the story of a patient’s clinical picture in as much
detail as is required to accurately re-tell the story. The story

should describe in sufficient detail what took place, what the
thought processes were, and what instructions were given to

the patient. The records must be legible, and the accuracy of the
medical record must be unquestionable. The objectivity of the

medical record is of utmost importance in order to demonstrate
that the care was unbiased and professional. Remember that

the medical record is a legal document, and the documentation
within the record will reflect the approach you and your staff

have in providing care for your patients.

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