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MEDICAL MALPRACTICE
and memories dim — but the medical record remains.
Plaintiffs' lawyers will look for alterations or the appearance of
alterations, contradictions, inconsistencies, omissions, time delays
and unexplained time gaps. These are the red flags and weak spots
plaintiffs' lawyers love to exploit in court.
Solid documentation, every time
Good medical records have many attributes. Documentation should
be labeled, legible, dated (with month, day, year and time), timely, factual, objective, accurate, consistent and complete. If you're using a
paper medical record, there shouldn't be unused pages or spaces. If
you're using an electronic health record, you should note blank fields
with an "N/A" or asterisk indicating that the field has been reviewed.
Avoid leaving a vague absence of documentation in the record. Let's
take a closer look at the 4 keys to good documentation:
• Factual: Record only what is known, not what's presumed. For
example, "Patient rated pain at a 0 on the pain rating scale," is more
factual than "Patient didn't appear to be in pain." Don't enter personal
opinions into documentation, and don't document long, defensive
notes in the medical record.
• Objective: Chart only what you see, hear, feel (as in touch, not emotion) and smell. For example, "Patient appeared to be her normal
self," does not objectively describe the patient's status.
• Timely: It's better to have a late note than a blank space in the
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