She's got bruises all over her face. She's got a gash. One of the simplest steps a clinician can take in documenting injuries is making sure that their handwriting is legible. Isaac found that one-third of the notes from doctors or nurses contained vital information that was impossible to read. Once they understand that these practices will make their records more useful, I think they will be inclined to make the appropriate changes to the way they document visits.
Illegible notes are useless as legal documentation.
Legal terms are defined in detail by statute and case law. By using legal terms, providers may convey an unintended meaning. Name the person the patient says hurt her by using quotation marks and recording the identifying information. This prevents the abuser from obscuring his responsibility by accusing the victim of having multiple partners. Conclusions without sufficient accompanying factual information are inadmissible.