Whether electronic or paper, appropriate, consistent, and accurate medical record documentation is a key aspect of patient safety and liability risk management. A complete medical record promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among all members of the healthcare team. Furthermore, what is, and more often what is not, documented in the record can be the pivotal factor in a malpractice lawsuit. From a risk management perspective, a complete record can help prevent or minimize the potential adverse consequences of malpractice litigation. Ultimately, the record serves as the basis for the defense of a malpractice claim or lawsuit.
CASE ONE CASE THREE CASE FOUR |
CASE FIVE CASE SEVEN CASE EIGHT |
Related Topics: Communication, Follow-up, Documentation, Informed Refusal
NORCAL Group Insureds
Access this article for CME credit.
Typically each Claims Rx provides an opportunity for NORCAL Group insureds to earn AMA PRA Category 1 Credit™ at no additional cost.
Not a Policyholder?
A featured complimentary Claims Rx is always available on the Claims Rx Directory main page, and all Claims Rx Directory articles with expired CME Credit are available for download.
© 2001 - 2023 ProAssurance
All rights reserved