Northwest Physicians Insurance Company
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Risk Management Tip |
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The Importance of the Medical Record November, 1997 The medical record is the most important document in defending physicians accused of professional liability. An unexpected poor outcome combined with a poor medical record can create a malpractice claim that is difficult to defend. On the other hand, a record that is complete, accurate, timely, and objective (CATO) can be extremely helpful in defending a physician. A properly documented record may even discourage a plaintiff attorney from pursuing a case. The medical record is thought to be the third witness of a trial. When debate occurs between the defendant and the plaintiff, research has revealed the medical record becomes the witness the jury will believe. For this reason it is sound risk management to have systems in place that support good record keeping. Over the years, medical records have served a number of purposes. Keeping notes to support patient care has always been a role. About thirty years ago, record keeping to reveal your rationale for treatment became necessary as professional liability became more frequent. More recently, a third reason for medical records has developed. This reason is to justify charges to third party payers. A problem that can compromise the defensibility of the medical record is when an entry is made late or after an unexpected complication. However, business offices may return a dictation for more complete dictation in order to base appropriate charges. This policy needs to be reviewed carefully. If the additional dictation appears to be a late entry after a complication has occurred, it could be very damaging to your defense. In summary, late entries should be made only when the information involved is important for patient care by yourself or another physician. The ideal goal is to have all entries in the record timely, which ordinarily would mean the day of the encounter. Reviewing your process of maintaining your records is a good investment. Improving patient care, assisting in risk management and satisfying the needs of your billing office are all sound reasons to treat the medical record process with high priority.
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503-371-8228 or 1-800-243-3503 |