Northwest Physicians Insurance Company
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Risk Management Tips |
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The Medical
Record The medical record is an essential part of providing medical care to your patients. It is also one of the most significant components in your defense in a medical malpractice suit. There are three witnesses of extreme importance in any trial; the plaintiff, the defendant, and the medical record. Trial consultants have done research that shows the witness the jury believes the most is the medical record. It is vital to review your system of record keeping and improve that system as needed. This is true for traditional or electronic medical records. The following list identifies a few important issues to consider as you review medical records: Ø Uniformity Ø Secure all pages Ø Organization Ø Timely record keeping Ø Legibility of handwritten notes Ø Accuracy Ø Corrections - one line through area of correction, initial & date Ø No disparaging comments directed at the patient or other physicians Ø Recording telephone calls This represents only a partial list of areas to review. From our experience with the Medical Office Risk Evaluation (MORE) program, these are areas worthy of your concern. In summary, what needs to be recorded on the medical record is what is accurate and necessary for patient care at the time of the entry. In addition, any self-serving comments on the chart are problematic and should be avoided. I hope this material will assist you in your risk management.
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Phone:
503-371-8228 or 1-800-243-3503 |