Medical malpractice matters: medical record M & Ms

J Surg Educ. 2009 Mar-Apr;66(2):113-7. doi: 10.1016/j.jsurg.2008.12.002.

Abstract

Accurate and thorough chart documentation is extremely important not only for patient continuity of care but also for medical legal risk reduction. It is common knowledge that a large percentage of court cases involving health care practitioners rely substantially on the chart documentation to determine outcomes. In this article, the authors have outlined particular court cases that illustrate the dramatic influence medical documentation has had in case law.

MeSH terms

  • Abortion, Legal
  • Antipsychotic Agents / therapeutic use
  • Documentation / standards
  • Fees and Charges / legislation & jurisprudence
  • Humans
  • Jurisprudence
  • Malpractice / legislation & jurisprudence*
  • Medical History Taking
  • Medical Records / legislation & jurisprudence*
  • Medical Records / standards
  • Psychotic Disorders / drug therapy
  • Refusal to Treat / legislation & jurisprudence
  • United States

Substances

  • Antipsychotic Agents