Claims of medical malpractice can severely damage the reputation of a healthcare professional. They can also cause major financial hardship by increasing the cost to carry malpractice insurance. Doctors generally need to provide a professional standard of care to all of their patients to protect themselves and their employers from frivolous malpractice allegations.
Adhering to best practices during the diagnostic process and when administering treatment is crucial for professional protection from malpractice allegations. Physicians and their support staff also need to prioritize thorough, accurate charting to reduce the likelihood of a medical malpractice claim.
Details can make all the difference when a physician responds to allegations of malpractice. Sadly, many medical professionals may fail to include key details in patient records that could help them exonerate themselves when accused of malpractice.
What deters accurate charting?
There are two factors that may prevent medical professionals from maintaining appropriately thorough charts. The first is pressure on a physician’s time. Many medical practices and hospitals demand that physicians see a challenging number of patients on any given day.
They may struggle to include adequate details in medical charts because of the pressure on their time. Some of them even wait until the end of the day to input information. At that point, they have likely forgotten key details that could make a difference in the event of a medical malpractice allegation. Making the time to record key details as quickly as possible can make a huge difference.
The second deterrent to thorough charting is concern about patient conflict. Under the Health Insurance Portability and Accountability Act (HIPAA), patients have the right to access their medical records. Doctors may worry about making notes in charts indicating that they disbelieve the patient or witnessed what they believe to be drug-seeking behavior.
While the use of civil language when charting is important, physicians should not avoid mentioning their concerns or limiting the details that they include in charts out of fear of offending the patient in the future. Thorough charting can help establish that a health care professional fulfilled their obligations and that a patient may have misrepresented the situation.
Reviewing internal records with a skilled legal team is often the first step toward developing a defense strategy when facing allegations of medical malpractice. Doctors who keep thorough charts may have an easier time vindicating themselves when facing malpractice allegations.
