Why Detailed Medical Charting Is Important to Avoid Allegation of Medical Malpractice

by | Published on Apr 6, 2016 | Medical Record Review

Attorneys handling medical litigation often utilize reliable medical record review services that not only help them have a clear awareness of the case and its various medical aspects, but also save them considerable time and effort. Legal experts caution physicians who make errors and adopt a casual approach to details in patient records. While errors in the medical records are detrimental for the patient, they question the integrity and dedication of the healthcare provider and put him/her in a negative light. Take the case of a provider who has not recorded the fact that he/she has reviewed the patient’s X-ray records and lab reports during a consultation. The patient may have further undergone a serious surgery and suffered a poor outcome. This will surely lead to medical malpractice litigation, and since there is no record as to the physician having reviewed the documents, his/her claim that they did look at those records will not have any value in court.

There is an increasing number of liability cases associated with flawed medical charting, as legal experts would point out. These discrepancies are used by plaintiff attorneys to show negligence, slackness or lack of integrity of the healthcare provider.

  • Poor charting is damaging to the medical provider, whether it is on paper or EHR.
  • Incomplete or missing information is one of the most common errors physicians make. This happens especially with doctors who work under tremendous stress and are hard pressed for time. Often, these doctors fail to note down the full extent of their treatment.
  • In other instances, they forget to include all that they discussed with the patients. These missing details are what plaintiff attorneys look for.
  • Another concern is doctors failing to chart text conversations with medical staff about their patients. Doctors may communicate with nurses and others by text to ask for updates regarding a patient’s condition or to provide medical opinion. If they don’t record these on the medical chart, and a lawsuit occurs, it is as if such communication never took place.
  • Faulty electronic health record systems are also to blame in many medical malpractice cases. These are supposed to be helpful to healthcare providers, but can make them appear negligent and mechanical.
  • Some EHR systems enter information into the medical record by default, and this can sometimes be inaccurate.
  • Another issue with EHR is the possibility of the physician copy-pasting information from one chart to another, which can prove really detrimental in medical negligence cases.

There is no doubt that poor documentation habit is the worst enemy of a physician. Comprehensive documentation is necessary to avoid any kind of ambiguity regarding the patient medical records. All care providers in a team including physicians, nurses and other staff should use consistent terms and words in the medical charts. This will help avoid charting mistakes. All conversations with patients and caregivers must be charted; most importantly consent provided for a treatment must necessarily be documented to prevent issues such as lack of informed consent in case a malpractice case arises. Providers must ensure that the medical chart contains documentation supporting the fact that they have discussed the benefits and risks of a particular treatment with the patient, and that the patient has made an informed decision and given approval to proceed with the treatment.

Physicians need not be unduly stressed about the medical record review process associated with medical litigation if their patient healthcare documentation is foolproof. By being especially conscientious in charting when dealing with high-risk patients and extremely sensitive situations, healthcare providers can avoid negative outcomes in medical malpractice lawsuits against them.

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