Charting With a Jury in Mind
Author: Jacqueline Moore, PhD, RN,CCHP-A.; Brian Spears.
Source: Volume 12, Number 03, March/April 2011 , pp.33-37(5)
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Abstract:
Proper charting, whether in a paper record or an electronic medical record, helps health care providers deliver sound patient care. However, practitioners should remember that charts are also important evidence in malpractice litigation. They can help you or harm you, depending upon what and how you recorded your interaction with patients. In any malpractice or civil rights case, one of the attorneys will offer the patient’s medical record as evidence.Keywords: Malpractice litigation, standard of care, liability, omission, ADA
Affiliations:
1: Moore & Associates; 2: Georgia Trial Lawyers Association.