What Not to Include in a Medical Record

Medical records can be physicians' best defense - or worst enemy - when they are faced with malpractice allegations. Too often physicians use the medical record as a personal diary for interactions with patients and staff. Unfortunately, the plaintiff can easily use this information, which more than likely has nothing to do with care rendered, to create doubt in the minds of the jury. The following is a list of items you should not include in the medical entry: 

  • Financial or health insurance information,
  • Subjective opinions,
  • Speculations,
  • Blame of others or self-doubt,
  • Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
  • Unprofessional or personal comments about the patient, or
  • Derogatory comments about colleagues or their treatment of the patient.

 

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