Six tips to improve your medical records
When a client alleges malpractice, one of your key defense tools is the patient’s medical record. Attorneys often say that if it’s not documented, it did not happen.
- Document medical treatment plans and have clients sign consent forms.
- Document client declinations of recommendations or procedures.
- Document communications including phone calls, emails, texts, and verbal conversations.
- Document history of complete physical exam and procedures including detailed anesthetics and surgical reports.
- Document boarded patient information such as elimination, appetite, and weight, especially for medical boarders.
- Use a computer-based record system, or ensure handwritten material is legible.
Tips provided by AVMA-PLIT