Principles of good medical record documentation.
Although the world of medicine seems to be changing and progressing with each day, one thing that has not changed is the need for good documentation. The medical record of today does not only reflect your care of the patient, but has become a communication tool to a wide variety of players. Everyone seems to looking at your records, from colleagues to HMOs, and in the worst-case scenario, a plaintiff's attorney. This article will help show why good documentation is so important not only for good medical care, but if needed, as a defense tool if faced with a medical malpractice claim.
Murphy
B J
BJ
Illinois State Medical Insurance Services, Inc., 20 N. Michigan Avenue, Suite 700, Chicago, IL 60602, USA. Murphy@ismie.com
D004282:Documentation / Q000379:methods*; D005568:Forms and Records Control / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D011216:Practice Management, Medical