When a malpractice lawsuit is filed, lack of documentation can significantly complicate the process of proving the patient’s treatment met the standard of care and did not cause the patient’s injury. In the following case, the emergency department (ED) physician failed to adequately document three different aspects of the patient’s care: her disruptive behavior, her departure from the ED against medical advice (AMA), and her follow-up telephone conversation. Each failure complicated the defense of the ED physician’s case.
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