More malpractice cases are settled or lost in trial because of the poor quality of records than because of the poor quality of care. In our society, meaningful documentation is a sine qua non for many important and routine transactions. Or a contract for a major purchase that's not even written or signed until weeks after money has changed hands. None of us would tolerate such documentation shortcomings in everyday life. Nevertheless, many medical records, on which present and future care or the defense of a malpractice case depend, suffer from similar vague language, lack of detail, and untimely preparation.
Medical records are legal documents.
Weak records are the most generous gift physicians and hospitals give to plaintiffs' attorneys whose goal it is to convince a jury of the facts that a bad outcome was not an acceptable complication of appropriate treatment, or an act of God or Nature, but instead was the result of negligence committed by an incompetent or inattentive healthcare professional. Hundreds of articles have been written about how to do this. Help also is available from liability insurance companies. No other profession tolerates the poor documentation practices many physicians tacitly condone. Some patients initiate legal action simply because they can't get the physician's attention any other way.