Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Regulating Health Care
Lecture:The Role of Medical Records in U.S. Health Care
Slide content:Quality Clinical Documentation for Legal Purposes Hand-written documentation Illegibility introduces malpractice risk Electronic documentation Mistakes can be made, but the legibility of health record content is improved More detailed notes What isnt documented isnt done 9
Slide notes:Hand-written documentation may be illegible, and mistakes can be made when interpreting the provider s intentions about treatment. When mistakes occur because of illegible handwriting, the health care facility is at risk for malpractice claims in a court of law. Although mistakes can still be made in an electronic documentation system, illegibility of handwriting will not occur. Clinical documentation will not protect a health care organization from litigation unless the content is thorough enough to communicate with the members of the health care team about the treatment. Therefore, the health record must provide clear and honest reflections of the care needed or given to patients. There is an old adage, What isn t documented isn t done. If the health record does not indicate what is actually done for the patient, the health record as a legal document does not hold up in court. 9