Magazine article Medical Economics

Legibility, Accuracy, Specificity Vital in Records

Magazine article Medical Economics

Legibility, Accuracy, Specificity Vital in Records

Article excerpt

The increasing prevalence of electronic health records should help address the issue of illegible medical records in the future. Of course, the main purpose of the record is to communicate with other healthcare professionals, and a legible record facilitates that purpose. A secondary purpose of the record, however, is to create a good legal document for evidence, and legibility also contributes toward that end.

If you are writing notes by hand, you must take the time to make your records readable to other healthcare practitioners as well as to any potential jurors. This advice seems like common sense, but examples abound of cases in which physicians did not heed it.

Take a look at the examples provided here. Ask yourself what it would be like trying to review these records if you were called in as a consultant or what you might think if you were a juror in a case in which these records were presented as evidence.

If the doctor reads his or her own records and says that he or she ordered lab work, but the jury can't decipher the doctor's handwriting, the jurors may not believe that the doctor/defendant in a failure-to-diagnose case actually did prescribe lab work. A plaintiff's attorney might say, "So, only you and God know what the record says?"

Even worse are cases in which a doctor cannot read his or her own records. The documents are virtually useless for the defense. Similar to the aforementioned case, the plaintiff's attorney might say, "Doctor, at the time you wrote this note, only you and God knew what it said, and now only God does? …

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