A medical malpractice lawsuit may happen years after a medical mistake injures or kills the patient. If medical malpractice does harm a patient, the patient’s records often provide vital clues as to what went wrong. Faulty medical charting can demonstrate when a doctor missed a crucial step or indicate a casual or careless approach to medical care. The legal community responsible for representing doctors and hospitals in medical malpractice cases has recently begun emphasizing the importance of record keeping and a detailed charting in avoiding medical malpractice lawsuits. An incomplete or inaccurate chart can be used to demonstrate an unprofessional approach to providing medical care.
The importance of carefully documenting the medical care provided to a patient should not be underestimated. The American medical system has moved away from the old model of a single, primary doctor handling most of the care for a patient. As treatment has become more specialized, the need for documentation and communication has grown. Patients are often handled by teams of doctors, each with his or her own specialty. Accurate records reduce the chance of an error resulting from a handoff from one care provider to the next.
Medical providers have the responsibility to accurately record the details of the treatments they order. Diagnoses and treatments are difficult or impossible to review if doctors do not keep appropriate records. With new innovations in electronic health records, record-keeping should be easier than ever.
Source: American Medical News, “Medical charting errors can drive patient liability suits,” by Alicia Gallegos, 25 March 2013