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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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6 Responses

  1. A Paper Lover,

    I still use paper records, and will take the 1% Medicare payment “hit.”.
    Also, file my tax returns with paper, not electronically.

    Dr. Dee

    Like

  2. Obamacare Will Boost Malpractice Claims
    [RAND Study Says]

    The healthcare reform law will reduce liability payouts by insurers for auto and workers’ compensation claims by nearly $1.7 billion annually while increasing medical malpractice claims by $120 million a year, according to a new study released by the RAND Institute for Civil Justice. The RAND researchers looked at the anticipated impact on insurance claims under the ACA in 2016, when the law is expected to be fully implemented.

    While the law’s most obvious impact will be on health insurance policies, researchers found that it will also have minor but financially significant effects on claims paid by other common types of insurance policies. The RAND researchers looked at the anticipated impact on insurance claims under the ACA in 2016, when the law is expected to be fully implemented. While the law’s most obvious impact will be on health insurance policies, researchers found that it will also have minor but financially significant effects on claims paid by other common types of insurance policies.

    Source: Paul Demko, Modern Healthcare [4/14/14]

    Like

  3. Liability Reduction

    In order to help strengthen personalized healthcare, reduce human error and enhance patient safety; our hospital in Hong Kong had implemented a patient infotainment terminal system at the bedside of every inpatient.

    The touch screen monitor mounted to the ceiling/wall allows instant access to clinical information by the physician and nurses such as the patient record, patient assessment form, allergy, radiological images and reports, laboratory results, histopathology results and nuclear medicine & PET reports as well as verification / data entry / ordering of any of additional medical services. This informatics system ensures that record keeping, careful medication and verifications are done in accordance according to physician’s order.

    Although there is no bullet-proof system that can totally eliminate malpractice defense; we found that medical errors have been gradually reduced since first introduction of the system in 2009.

    However, we still get the ambient odd complaint from our patients from time-to-time.

    Ken Yeung MBA CMP™ candidate

    Like

  4. Headlines

    “EHRs Are Full of Legal Risks – Many physicians are so concerned about being sued for malpractice that they routinely order unnecessary tests and procedures to practice defensive medicine. And yet, when it comes to legal risks in using their electronic health records (EHRs), their concern is often nonexistent, experts assert.”

    Neil Chesanow for Medscape
    August 26, 2014

    Like

  5. Reduction in Malpractice

    Premiums Malpractice premiums will continue to drop in 2015.

    For instance, premiums for three specialties including, general surgeons, internists and OB / GYN reduced in 2014. These specialties have been experiencing 13% decline in its premiums since 2008.

    Gwen

    Like

  6. Physician-Patient Relationships

    MN Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs for Malpractice

    https://www.mnmed.org/news-and-publications/News/MN-Supreme-Court-Rules-Physician-Patient-Relations?utm_source=Informz+Email&utm_medium=Informz&utm_campaign=Informz+Emails&_zs=7CPLX&_zl=kE8b1

    So, will Physician-Relationships become adversarial?

    Dr. David E. Marcinko MBA

    Like

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