While medical records are often the last concern of a physician during treatment, the documents included in a patient’s chart and office records are often the foundation for a physician’s defense against medical malpractice claims. How can medical paperwork help a professional to fight back against claims that they made a mistake or provided an unprofessional standard of care?
By affirming how the doctor assisted the patient
The individual chart entries created at every medical appointment will typically include records of the topics discussed by the patient and their doctor, any treatments or testing ordered and the conclusion that the physician reached. A review of those records could help establish that a doctor ordered testing or medication for a patient, but the patient failed to follow up on those recommendations. The records could also raise questions about whether or not patients actually communicated certain symptoms to their doctors. The more thorough physicians are with their charts, the easier it will be to establish that they provided an appropriate standard of care for the patient.
By clarifying that the patient knew the risks
Physicians will often have patients fill out informed consent documents and other paperwork acknowledging the risks, failure rates and side effects associated with different treatments. Patients who are unhappy with the outcome of less-common medical procedures may try to hold the physician accountable even if they had previously heard about the potential risks involved with their treatment choice.
Medical practices with appropriate intake paperwork and excellent charting standards will be in a better position to respond proactively to medical malpractice claims. Recognizing that medical malpractice claims can happen even to the most diligent professionals may help care providers take the necessary steps to protect themselves and their practice from questionable allegations made by patients.
