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CLAIMS Rx DIRECTORY


RISK MANAGEMENT PUBLICATION

Medical Record Documentation Risks and Strategies

May 2021

Whether electronic or paper, appropriate, consistent, and accurate medical record documentation is a key aspect of patient safety and liability risk management. A complete medical record promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among all members of the healthcare team. Furthermore, what is, and more often what is not, documented in the record can be the pivotal factor in a malpractice lawsuit. From a risk management perspective, a complete record can help prevent or minimize the potential adverse consequences of malpractice litigation. Ultimately, the record serves as the basis for the defense of a malpractice claim or lawsuit.

CASE ONE 
Incomplete Documentation

CASE TWO
Inadequate Documentation of Patient Refusal of Treatment

CASE THREE
Self-Serving and Fraudulent Medical Record Corrections

CASE FOUR
Multiple Corrections to Template-Generated Default Content

CASE FIVE 
Uncorrected Template-Generated Default Content

CASE SIX
Failure to Correct Copied and Pasted Content

CASE SEVEN
Texting Patients

CASE EIGHT
Failure to Adequately Review the Medical Record

 

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