title: Documentation and record keeping in clinical practice.
abstract: Attorneys are often handicapped by inadequate, illegible records in defending optometric malpractice claims. Many practitioners record only the abnormal conditions they observe, and thus in the future there may be no way to verify what tests were performed during the examination. Good records should reflect every aspect of the encounter with the patient, including history, findings (normal and abnormal), treatment, and referrals.
mesh_terms: D005260:Female; D006801:Humans; D007351:Insurance, Liability / Q000331:legislation & jurisprudence; D008318:Malpractice; D008499:Medical Records; D009907:Optometry; D011216:Practice Management, Medical; D014481:United States