Risk Management Frequently Asked Questions

What documentation should be included in a patient’s medical record?

Good documentation in the patient’s record can be a primary defense against allegations of malpractice. A well-documented patient record may actually prevent a lawsuit from being filed. On the other hand, poor documentation or alterations in the patient record can render an otherwise defensible case indefensible. Patient record documentation should accurately reflect the care and treatment provided to a patient and that the standard of care was rendered. Good documentation is also crucial in the coordination and communication of patient care with other healthcare providers and to justify billing. Documentation should be legible, accurate, clinically relevant, chronological, objective, clear, complete and specific.

The advent of EHR-based patient record documentation comes with many advantages, but also many hazards, as discussed in the following sections.

Click here for a comprehensive documentation guide for paper and electronic patient records, Documentation 101.


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Legal Notice and Disclaimer
DISCLAIMER: Please note that the information contained in these resources does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only and is written from a risk management perspective to aid in reducing professional liability exposure. Please review these documents for applicability to your specific practice. You are encouraged to consult with your personal attorney for legal advice, as specific legal requirements may vary from state to state.