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Documentation

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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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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Reducing the Occurrence of Malpractice Cases Involving Insufficient Documentation

To prevent documentation related cases, consider chart audits along with education regarding what critical information is too often not captured within the patient’s record(s).

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Where Errors Occur

Getting and keeping a complete and up-to-date medical history database can be difficult. Yet family and medication history are known places where errors that can lead to patient harm occur.

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