Contents Legal system Malpractice Avoiding malpractice Medical record Introduction Proper documentation Subjective vs objective Legal considerations Managing records Record storage Releasing records Viewing records Withholding records Selling records FAQs Patients' rights QUIZ

Legal considerations For legal purposes, most written records are considered hearsay and therefore not admissible. Medical records, however are considered "business records" if they fulfill certain criteria (made contemporaneously with events it reports, entries were made by person connected with events recorded, records are kept in the regular course of business), and as such they are readily admissible in most cases. Notes that are kept off-chart, like index cards kept by resident physicians, complicate medical record keeping in the follow manner: Index cards are filled out immediately after seeing the patient...the "official" medical record is then filled out at a later date and is thus considered a "secondary medical record". Secondary medical records are considered less reliable and more likely to be slanted to reflect what should have happened than what actually happened. It is often argued that "a good medical record is the best defense", however, the intense focus now placed on the medical record as a legal document actually diminishes both its medical and legal effectiveness (because of the possibility of slanting the record as noted above). Also, although a poorly kept medical record may prevent one from establishing that good medical care was given to a patient, a "good" medical record is no substitute for good medical care. A carefully organized, well-written medical record created by capable practitioners can be an excellent defense in a malpractice suit; a poorly-written, incomplete or disorganized medical record, while not exactly evidence of negligence, does demonstrate practitioner incompetence and substandard care. Illegible records are always a favorite among plaintiffs' (i.e., patients') attorneys. The medical record should never be used as an instrument to complain about: The patient or his/her family Nurses, physicians or other caregivers The health care institution Nor should it be used as a battleground for caregivers.