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Medical Malpractice: Documenting 101

Medical Malpractice: Documenting 101

“Document, document, document” is the usual refrain. Actually, documentation is a perfect example of the Goldilocks Rule: There can be too much or too little, but then there is the amount that is just right. When you create a medical record, you create a legal document that is, in fact, one of the exceptions to the Hearsay Rule in that it is an out-of-court statement that can be entered into evidence as proof that what it says is true. Therefore, as I say when I lecture on medical malpractice, “You want to say things in your words because otherwise I, as the plaintiff’s lawyer, will be saying them in mine.” 1. First, write a note that can be read. As we move to full EHR this is less of an issue but still remember that you can end up being named in a case and deposed simply because your note, that would have otherwise explained your non-role, was illegible. Since the only time you worry about documentation is when you either know that things have hit the fan or you suspect that they might, your first impulse will therefore be self-protection, and you will want to try to fill in every possible issue. This natural instinct will produce notes that are long narratives that go back into the past and are filled with extraneous facts  that themselves serve not to explain the patient’s condition but your own conduct. That is why you have to restrain yourself. Otherwise, you will create a statement that stands out from the rest of the record like a very sore thumb and will have just told a plaintiff’s attorney or board investigator where to...
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