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Ask the expert: Are residents held liable for documentation errors?

Residency Program Connection, May 22, 2007

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The clinical record is the basis for all clinical decision-making in a healthcare facility. When documentation errors occur, medical malpractice claims may result, and depending on state regulations and case law, both licensed and unlicensed residents might be found liable for medical malpractice claims, including those associated with documentation errors. In addition, once residents receive their state medical license, they are held to the same standard of care as all physicians in the medical community. A resident will therefore be liable for medical malpractice if his or her conduct falls below the community's standard of care or causes injury to the patient.

When it comes to litigation, an ounce of prevention is worth much more than a pound of cure. The clinical record is the most important legal document in any liability suit. The rule of thumb is, "If it is not in the record, it didn't happen." If an entry is made after the event it describes, the entry's validity can be challenged in a court of law.

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