AAO-HNSF Certificate Program for Otolaryngology Personnel

Reprinted with permission from The Journal of Medical Practice Management , Copyright 2001, Vol. 16 #5 pages 258-260, Greenbranch Publishing LLC, PO Box 208, Phoenix MD 21131, 800-933-3711, www.mpmnetwork.com. For a sample issue of the Journal please contact ncollins@greenbranch.com. Principles of Good Medical Record Documentation Although the world of medicine seems to be changing and progressing with each day, one thing that has not changed is the need for good documentation. The medical record of today does not only reflect your care of the patient, but has become a communication tool to a wide variety of players. Everyone seems to looking at your records, from colleagues to HMOs, and in the worst-case scenario, a plaintiff’s attorney. This article will help show why good documentation is so important not only for good medical care, but if needed, as a defense tool if faced with a medical malpractice claim. Brian J. Murphy

Key words: Documentation; malpractice; SOAP method; medical record keeping.

INTRODUCTION

Have you ever thought of making an addition to a patient medical record, even as innocent as to clarify a point, document a conversation, or write down examination findings that you may have forgotten at the time of the visit? Alterations such as these, unless done in a timely fashion, may render your case indefensible. Complete medical records are the cornerstones of quality health care. They provide information used for planning the patient’s continuum of care; serve as a communication vehicle with other health care providers; are used for quality assurance; support billing and reimbursement; and are the best tools for the defense of a medical malpractice claim.

BASICS OF MEDICAL DOCUMENTATION

Throughout the course of a medical malpractice case, the most important piece of evidence will be the medical record. The loss of many cases can be directly attributed to poorly maintained medical records or lack of documentation in the patient’s medical record. If your records are accurate, legible, and well organized, they will greatly increase your chances of successfully defending a malpractice suit.

Throughout a medical malpractice case, the most important piece of evidence will be the medical record.

The “Golden Rule” in documentation is “If it isn’t written down, you didn’t do it.” Every entry should stand independently and provide enough information so a new care giver reviewing the medical record would know exactly what the patient was being seen for, their course of treatment, and the physician’s plan of action. The following guidelines