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Six tips to improve your medical records

  |   Practice Management

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.

  1. Document medical treatment plans and have clients sign consent forms.
  2. Document client declinations of recommendations or procedures.
  3. Document communications including phone calls, emails, texts, and verbal conversations.
  4. Document history of complete physical exam and procedures including detailed anesthetics and surgical reports.
  5. Document boarded patient information such as elimination, appetite, and weight, especially for medical boarders.
  6. Use a computer-based record system, or ensure handwritten material is legible.

Tips provided by AVMA-PLIT