Medical malpractice matters: medical record.

1 he medical record is a legal document that is admissible as vidence in a court of law. Although neither the physician or the ospital owns the physical chart, the patient owns the informaion inside of it. As a legal document, the medical record can be dministered in a court of law for litigation regarding any of the ollowing issues: personal injury, worker’s compensation, child ustody, or employment disputes. In addition, the informaion in the medical record is used for the purposes of medical alpractice actions. Initially, physicians kept medical records simply to remind hemselves of previous treatments, to inform future providers of revious care, and to enable the office to generate accurate bills. n our current age of super subspecialists, treatment teams, and hird-party payers, these reasons for maintaining the medical ecord still hold true and are probably more pertinent now than ver before. However, in addition to these traditional reasons, aintenance of accurate medical records today is of utmost mportance as a means to minimize the potentially adverse conequences of malpractice claims. In fact, some assert that for a ractitioner being challenged with a lawsuit, a well-docuented medical record serves as her primary and best legal efense. On the contrary, poor documentation can be “the kiss of eath” for a physicians’ malpractice defense. Sloppy record eeping will not only undermine the credibility of the practiioner being sued, but it can also make a malpractice case literlly indefensible in court. No matter whether the standard of are was provided, even remotely ambiguous entries into the hart will be to the physician’s disadvantage in court because mbiguous records create questions of fact regarding treatment hat was given to a patient. Such questions of fact when preented by a convincing attorney may be the only element eeded to persuade a jury to find liability against a health-care rovider defendant. Nevertheless, there are positive aspects to documentation. he first piece of good news is that the physician completely ontrols the entry into the medical record, which means that the hysician has the ultimate authority to describe the events of atient care as it was administered. This fact is important beause in a court of law, the medical record will usually take legal