Documentation

Where Errors Occur

Obtaining and maintaining a complete and up-to-date medical history database—and providing that information when needed to all medical personnel—is hindered by the complexity of our health care system, advances in medical science, and the aging of our population. At the same time, family history and medication history are recognized as places where errors that can lead to patient harm occur. CONTINUE READING >

OB Guideline 1: Documenting for Patient Safety

The medical record is a sequential record of patient care, a storage place for diagnostic test results, a communication tool for clinicians, and a legal document. CONTINUE READING >

41% of cases end with payment to the patient when poor documentation is involved.

Delay in Postop Hematoma Diagnosis Causes Paralysis

This case was complicated by the disconnect between what was documented and subsequent testimony by two physicians who recall different versions of a discussion.

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Documentation Dos and Don’ts If it wasn’t documented…

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Documentation Dos and Don’ts

CRICO Staff

September 15, 2002

Current, complete records which assist diagnosis and treatment, and which communicate pertinent information to other caregivers also provide excellent records for risk management purposes. Missing, incomplete, or illegible documentation can seriously impede patient care and the defense of a malpractice claim, even when the care was appropriate.
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Patient receives blood transfusion against her wishes Husband gave permission based on a note written by the patient to him

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Patient receives blood transfusion against her wishes

Eileen Shanley, CRICO

October 11, 2006

A 44-year-old Jehovah's Witness received blood transfusions during treatment for necrotizing pancreatitis.
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Legal Report: Three Risks to Avoid in Health IT Be on the lookout for inaccurate templates, inconsistent records across formats, and missing information from print-outs.

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Legal Report: Three Risks to Avoid in Health IT

Ellen Epstein Cohen, JD, Adler, Cohen, Harvey, Wakeman, Guekguezian, LLP

January 1, 2008

As we transition from the traditional “paper chart” to a variety of electronic medical systems, many issues arise that have direct implications for the effective defense of malpractice cases. Here are three quick concerns.
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General Informed Consent Guidelines It is the physician’s responsibility

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General Informed Consent Guidelines

Jock Hoffman, CRICO

May 5, 2011

These guidelines are based in part on opinions and advice of malpractice defense attorneys in Massachusetts. CRICO recognizes that institutions should continue to have the flexibility to respond to such recommendations in a manner that will least disrupt the orderly provision of health care at the facility.
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Documentation

Where Errors Occur

OB Guideline 1: Documenting for Patient Safety

Delay in Postop Hematoma Diagnosis Causes Paralysis

Featured

Documentation Dos and Don’ts

Patient receives blood transfusion against her wishes

Legal Report: Three Risks to Avoid in Health IT

General Informed Consent Guidelines