Residency

The importance of good documentation

Residency Program Insider, November 7, 2005

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Have your residents been taught the value of good documentation? Good documentation has always been a recognized way to reduce malpractice exposure. For years, healthcare professionals have heard that "if it is not document, it was not done." Clear documentation reduces liability exposure in a number of ways. Good documentation can prevent medical errors and a safer patient care environment. Many articles have been written about mistakes dues to illegible notes. Juries have awarded large sums in medical error cases that have resulted from a physician's sloppy handwriting.

There is little humor in jokes about physicians' handwriting these days. Plaintiffs' attorneys look for poor handwriting. They look for a note that cannot be read and use technology to blow it up to the size of a movie screen in the courtroom. These attorneys ask jurors whether they can read the note and, when they can't, ask how the physician could have expected anyone to read it. They try to illustrate how sloppy documentation and messy handwriting is indicative of a messy and careless physician.

We must practice offensive, rather than defensive, documentation. Residents must be taught to use documentation as a net to catch the excellent care they provide. Good documentation systems can show that patients are well-informed and understand the critical role they play in their recovery.

That's all for this week!

All the best,

James W. Saxton, Esq.
Stevens & Lee



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