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For Better Care... Write It Down


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For Better Care... Write It Down

By William Berry, MD, CRICO

Related to: Ambulatory, Communication, Cures Act: Opening Notes, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

When a malpractice case goes to court, the documentation in the medical record takes center stage, because while human memories fade, facts written down do not. If you wrote it down, it happened. If you didn’t—well, “maybe” it happened. Rather than focusing on the need for accurate documentation to defend care in a jury trial, which is a rare occurrence, let's consider some of the other important reasons to establish and maintain good medical records.

We all recognize how important communication is in providing safe, quality care to our patients. The medical record continues to be one of the most powerful tools to help us do this. Writing down pertinent findings in a patient’s history and physical exam shows that we listened and we looked. This is good for defending our care, but it also lets others seeing the patient know what we heard and saw. When we're not there to care for our patients, and no one can be there all the time, the medical record carries our thoughts, concerns, observations, and plans—but only if we took the time to commit them to paper.

The medical record can serve as a reminder for us as well. Is the complaint old or new? Is the lump bigger or smaller? Valuable information is lost when we don’t write it down. That missing information could change a diagnosis or help make one when things are hard to figure out.

As physicians, we dislike being forced to make decisions in a vacuum and we complain about not having the records we need to take care of our patients. Yet, all too often, we're the ones who don’t take the time to write things down clearly and legibly so that patients get the care they need.

Next time you hear “Document, document, document,” think,“It’s better care, better care, better care for my patient.”

And better care saves lives.

September 1, 2006
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