" Record what you have seen; make a note at the time; do not wait. " - Sir William Osler Most doctors dislike paperwork – especially that involved in entering information in medical records. Thus, while most surgeons enjoy operating, many treat documenting the medical details in the record as a painful chore which they would rather not do. This often means that entering data into the medical chart is delegated to a junior or inexperienced assistant, as a result of which it is often not done well.
Remember that the medical record serves many purposes , and its primary function is to plan for patient care. However, from the risk management perspective, the medical record is a crucial element in preventing and minimizing malpractice litigation. Ultimately, it serves as the basis for the defense of malpractice claims and lawsuits. Medical records which are poorly maintained, incomplete,…
