Record, in a prominent place, any drug allergies or adverse reactions. Record arrangements for follow-up and referrals made. Record prominently any advance directives made by the patient prohibiting certain treatment options. Therefore, a good medical record serves the interests of the medical practitioner as well as his patients. Illegibility, inadequacy or absence dooms almost half of medical negligence cases.
Medical records are often the only source of truth.
They are likely to be far more reliable than memory. Abbreviations Keep in mind that abbreviations may not be understood by others. Also do not used coded messages to express exasperation, sarcasm or your poor opinion of the patient. The courts would view very seriously any attempt to rewrite notes that will be used as evidence in legal proceedings. If you later discover that something you have written was inaccurate, misleading or incomplete, insert an additional note as a correction.