At TMLT, we’ve been telling physicians about good documentation techniques for 30 years. And because good advice never goes out of style, we’re re-publishing an article on documentation from August 1989.
Document doctor document
Documentation: Physician friend or foe?
The record you generate in the care and management of your patients can be your best defense or your worst enemy, when a claim of negligence arises. This issue of the TMLT Reporter is intended to summarize the importance of attention to detail in recording your assessment, medical judgement and outcomes in the practice of medicine.
When is the medical record a “source of defensibility” in a professional liability claim?
1. When records are legible, chronological and true (clarity and reliability)
2. When records clearly indicate why a patient seeks your services (motivation)
3. When records clearly indicate what is wrong or the presenting picture of the patient (assessment).
4. When records clearly indicate from your assessment the thought process you use to establish a range of conditions for which you may be dealing (differential diagnosis).
5. When records clearly indicate the method(s) of treatment you and your patient select (plan of care).
6. When records clearly indicate that the patient comprehends and authorizes said plan of care, whether medical or surgical (informed consent).
7. When records clearly indicate that the plan of care is monitored or measured as to an effect on the condition being treated (follow-up).
The above 7-step plan is quite simple, minimally time-consuming and smart. In fact, within the text of these 7 steps are keys to the more common medical records weaknesses which come directly into review and subsequent criticism by opposing forces in a professional liability claim.