In many cases, a medical practitioner becomes a defendant in a medical malpractice suit years after the care at issue was provided to the patient. If medical malpractice does harm a patient, the patient’s records often provide substantial clues as to what went wrong. But in many cases, no malpractice was actually committed, but because of sloppy record keeping, the plaintiff now has an issue to bring suit on. Unfortunately, it’s not uncommon for a plaintiff to initially make a claim under a particular theory of negligence, and subsequently change or add to their allegations, based on a defendant’s failure to accurately record events in the patient’s chart.
Without a doubt, proper charting substantially reduces the risk of being subjected to a suit for medical malpractice. In many cases, a plaintiff’s decision to bring suit rests on the documentation in the chart, and the reasoning behind the medical decisions that were made by the practitioner. The general rule regarding chart documentation is, “if it is not documented, it was not done.” A physician may testify that they performed a particular examination or procedure on the patient, but in the absence of a chart note to that effect, the plaintiff’s lawyer will do their best to convince the jury otherwise.
Accurate documentation also ensures proper continuity of care, especially in a team-oriented environment, such as a hospital. An accurate record of the observations and treatment provided by a previous practitioner is crucial to any subsequent care-giver. In addition to being useful in patient treatment, good documentation helps a medical practice with billing and other practice management issues. It is also critical in any legal proceeding.
One of the most important considerations in any medical malpractice case is the reasoning behind the treatment provided. Frequently, the outcome of a particular lawsuit rests primarily on the medical records. It’s not uncommon for a physician to be deposed, under oath, two to three years after an event has taken place, and there is usually no way for the doctor to independently recollect the patient, or any of the details of what happened during that person’s care and treatment. If the medical practitioner did not accurately or sufficiently document his or her involvement, medical diagnoses, and plan of treatment, it can significantly hinder the defense of the care given in a patient’s lawsuit brought years later.
For attorneys defending a practitioner against a claim for malpractice, documentation of the reasoning behind a diagnosis, or plan of treatment, is extremely valuable in defending a case. Adequate charting also shows that the practitioner cared about the individual patient, and their outcome, which is also critical to the defense of any case.