Effective documentation auspiciously captures these steps in a format that may derail erroneous charges or immediately exculpate the wrongly accused. Physicians typically approach documentation with the goal of communicating effectively with themselves. There is no quick and effective antidote to such allegations. The medical record should never be erased or altered, and once requested by a reviewer it cannot plausibly be amended. Rescission is impossible.
Prevention is necessary.
By guarding against a lengthy litigation process, it may be the ultimate time saver. My purpose is to share documentation techniques that improve communication, enhance patient care and decrease your risk of being charged with malpractice. Use direct patient quotes to demonstrate your attention to patients, highlight main areas of concern, build credibility into the record and accurately document a patient's competency, affect and attitude. Not unexpectedly, a patient's self-portrayal may markedly change between the time of your encounter and the time of an appearance before an attorney or jury. Patients' abusive or threatening words will sufficiently demonstrate their level of cooperation and credibility, while removing any biases in your interpretations.