Medical Record Documentation Risks and Strategies

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.