Documentation and informed consent.
Documentation remains the key factor that leads to success or failure of a claim in a significant number of cases. Since the time of a trial is often years later, an accurate memory can only be reflected by the records kept by the physician in question. This article focuses on developing good habits of documentation in areas such as medical record maintenance, handwriting, informed consent, and record tampering. Guidelines for improved record keeping are also presented in this article.
Weintraub
M I
MI
Department of Neurology, New York Medical College, Valhalla, New York, USA.
D004282:Documentation; D005104:Expert Testimony / Q000331:legislation & jurisprudence; D006801:Humans; D007258:Informed Consent / Q000331:legislation & jurisprudence*; D007351:Insurance, Liability / Q000331:legislation & jurisprudence; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008499:Medical Records / Q000331:legislation & jurisprudence*; D009462:Neurology / Q000331:legislation & jurisprudence*; D012017:Referral and Consultation / Q000331:legislation & jurisprudence; D014481:United States