Lack Of Meticulous Documentation And Positive Patient...

In the medical field there is an â€Å"age old saying, â€Å"if it is not documented in the medical record then it did not happen† the reality is, much happens that does not get documented† (Crozer-Keystone Health System, 2009, Para. 1). The question is, without documentation in the medical record, is the record complete, accurate, and concise? This is the question that everyone is asking in regards to the court system, without documentation is it malpractice or should physicians be able to document what is only necessary information. In this paper, we will be discussing whether or not meticulous documentation and positive patient interactions deter a lawsuit; will correlating patient expectations with clinical outcomes and assisting in patient decision making also deter a lawsuit; and lastly, protecting the integrity of the medical record, will that also deter a lawsuit. A medical record, whether in a physical record or an electronic form is a legal document that sh ould â€Å"reflect an accurate chronology of events† (Brous, E., 01 Feb., 2009, para. 2). Without exception, every entry must be dated with a year, time recorded with either am, pm, or in military time, and the medical record should be signed with a last name and the doctor’s status. Furthermore, the medical record should read like a book; as well as paint a picture of the patient so that others who reach the chart will know what the doctor saw and did to the patient. Doctors that document about the patient and what theShow MoreRelatedDeveloping Management Skills404131 Words   |  1617 PagesBuilding Relationships by Communicating Supportively Gaining Power and Influence 279 Motivating Others 323 Managing Conflict 373 PART III GROUP SKILLS 438 8 Empowering and Delegating 439 9 Building Effective Teams and Teamwork 489 10 Leading Positive Change 533 PART IV SPECIFIC COMMUNICATION SKILLS 590 591 Supplement A Making Oral and Written Presentations Supplement B Conducting Interviews 619 Supplement C Conducting Meetings 651 Appendix I Glossary 673 Appendix II References 683 Name