If it isn’t Written – It Didn’t Happen

Suffice it to say; when it comes to a trial for malpractice, a jury will most often believe that you did what you said you did if it’s written in the chart.

Do you have to write a book for each patient’s visit? No. But you do need to include enough information so that if someone else saw the patient at the next visit, he or she could tell from your note the patient’s diagnosis, what treatment you rendered, and the plan for follow up. If informed consent was given for a procedure, there should be a brief note that the consent conference was held (the consent form will have the rest of the details, so there’s no need to include them in the note).

So it’s patient care that dictates the need for documentation. But if, heaven forbid, you wind up defending yourself in front of a jury and you have documented the necessary parts of the care you rendered, the jury will more likely believe that you did what you said if it is in the chart.

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