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MEDICAL MALPRACTICE
Jan Kleinhesselink, RN, BSHM, and Carmen Lester, RN, JD
Suit-Proof Your Documentation
Charting errors can come back to haunt you if you're sued.
I
n a malpractice case,
the medical record can
be either your best friend
— or your worst enemy.
Documen-tation is meant
to provide the record of
patient care, the patient's
medical history, the basis
for billing and reimbursement, quality-of-care indi-
CHART THE COURSE The plaintiff's lawyer will dissect the medical record.
cators, and possibly clinical data for research and education.
Documentation is the story of the patient's experience across the continuum of care. But if your facility is sued for malpractice, the medical
record will suddenly become most invaluable as a legal document.
In court, the medical record is the care rendered. It will be introGET IT RIGHT
duced as evidence at trial. Jurors view good
The 5 Rights of
Documentation
record-keeping as an indicator of good care
1. having the right person
2. get the right information
3. about the right patient
4. on the right chart
5. at the right time
— poor documentation can create an aura
of poor care and damage your credibility.
Here's how defensive documentation can
protect you in the event of a suit.
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