Medical Records as Malpractice Defense

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A “Complete and Accurate” Record  

By J. Christopher Miller JD

J. Christopher Miller, Esq

The best defense against any medical malpractice liability claim is a complete and accurate written or electronic record of the facts.

To Observe and Treat

In particular, medical malpractice claims will frequently be stalled or thwarted by a consistent written description of the symptoms you observe and the treatments you prescribe.

Extensive record keeping will not only help formulate a defense against a claim, but it will also (and perhaps more importantly) create the appearance that you are careful and highly competent in all of your affairs. Members of a jury may not be able to discern whether the medical judgments you made in a particular case were good or bad, as they do not have the years of education and training that you do.

Trial Jurors

Jurors can, however, sense whether your practice is organized and professional. If your records are thorough and consistent, jurors will assume that you dedicate as much attention to the substantive aspects of your work as you do to the tedium of recordkeeping. If you are active in the management of your office, you should keep track of its operations and establish logs for your employees to complete as they perform their daily tasks.

Assessment

Not all information, however, ought to be written down. Keep your written records to the facts you have observed and leave your speculations for department meetings.

Conclusion

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