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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)

Correctional Health Care Report

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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.

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