Resident documentation risks

Residency Program Insider, April 25, 2006

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Resident documentation risks

Although residents typically share liability for malpractice claims with their supervising physicians and the healthcare facility, this does not absolve the residents of liability. If named as a defendant in a medical malpractice case, a resident, like attending physicians, must inform his or her malpractice carrier and cooperate with malpractice defense counsel to prepare a defense against the claim.

The clinical record, in addition to providing a defense against medical malpractice claims, provides a defense against claims of substandard care from state licensing and/or accreditation agencies and serves as the basis for third-party reimbursement. In order to prepare for review by internal and external auditors, the record should be filled out in accordance with the requirements of your institution and include accurate and complete information regarding care and services provided to the patient.

In today's litigious society, residents must understand that the clinical record can either avert a potential lawsuit or provide credence to a plaintiff allegations that the care provided was negligent or inadequate. The clinical record is quintessential in demonstrating that patient care was rendered in a manner consistent with the expectations and standards of the medical community.

Although documentation might seem to be burdensome or secondary on residents' list of priorities, it will be their salvation if a patient or a patient's family believes that the care provided did not meet expectations. This is especially true if a patient files a complaint or there is an adverse medical event that leads to an unexpected outcome.

All the best,

Andrew Blustein, Esq., Partner

Stacey Gulick, Esq.
Garfunkel, Wild & Travis, P.C.
Great Neck, NY

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