(Excerpted from the July 7, 2006 issue of Medical Economics)
How much is too much? Many physicians feel pressured by extremely high standards of documentation due to the threat of malpractice litigation. Like the "location" of real estate, experts shout "document, document, document" when it comes to managing the risks of malpractice litigation.
Obviously clear, accurate and complete documentation is necessary to primarily protect your patients. It helps prevent errors and injuries by subsequent treating physicians who rely on your records. And yes, it also protects you if you're sued for malpractice.
Good charting need not be onerous. Charts should contain enough information to prove that you've met standard of care protocols. They should include enough detail to justify your decisions on providing, changing or delaying treatment. They should contain patient complaints, as well as your history of treatment and physical findings. They should also include any drug or food allergies and the results of any tests and procedures.
Physicians who have good communication skills with their patients may sometimes be less thorough in their documentation. Short hand notes and abbreviations may be sufficient at the time of writing, but may be difficult to recall in detail years later. Your charts should have clear notes and comments in order to confirm the level of care when addressing a jury.
So heed the experts and continue the practice of maintaining careful, clear and thorough documentation. Its importance cannot be stressed enough!
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