Charting Your Course: Keeping Good Medical Records

When it comes to malpractice suits, a medical chart can be either your best friend or your worst enemy. Regardless of what happened in the exam room, unless it is on paper, it never happened. At least, that’s how a jury will see it, and how a patient will many times claim it. That’s why, in order to protect yourself and your reputation as a medical provider, you need to become excellent at keeping records.

A medical record is both a medical and a legal document. Detailed records are not only important for the patient’s care, but also for providing solid evidence in the case of a negative outcome. A thorough, accurate medical record provides evidence that a physician took appropriate actions, and it can be used in a court situation to reinforce the level of care provided. When a patient’s memory of the procedure fails to recall certain actions, the jury can look at the medical records to see what really took place during his or her treatment.

Many times, however, it’s not good enough just to keep good records. All charting must be done at key moments in the process in order to dispute any idea that they are illegitimate. Beginning with the new patient interview, each physician should gather detailed information regarding the patient’s medical history and obtain his or her previous medical records. Any information that is recorded incorrectly during this visit will lead to repeated care mistakes throughout the treatment.

It is also critical to document any differential diagnosis. Many times, a patient’s attorney will ask a defending physician how he or she reached a certain diagnosis while trying to prove that all of the possibilities weren’t considered. However, if a physician has kept good record of differential diagnoses, he or she can prove what options were considered and why others were dismissed.

Follow-up care must also be documented well. If a patient makes a complaint that goes ignored, it can be highly detrimental to a defending physician. Juries hold physicians to a higher level of responsibility than they do patients and expect doctors to prioritize patient calls, test results and any complaints that are made during the process. Juries view the management of these actions to be the physician’s responsibility and will usually find in favor of the patient if no records show that proper follow-through was provided. In order to avoid this, all complaints should be recorded along with the follow-up actions taken by physicians.

Informed consent is another critical area that must be noted and is legally required before a procedure is taken. Failure to secure the patient’s consent can put the physician at risk for any number of claims including medical battery. Documenting the informed consent interview, however, proves that the patient was aware of the situation and agreed with the treatment. The records must include the different treatment options along with the risks of the procedure. It should be signed by the patient and a witness, as well as the physician.

Notes taken during the procedure and treatment are also necessary. Juries tend to see detailed descriptions as indicators of attentive treatment and will take that into consideration when evaluating the case. Plus, detailed notes also provide evidence that a procedure was done properly and that a high level of care was taken even if the outcome is undesirable.

Finally, charting is also critical at the time of a patient’s discharge. When a physician releases a patient, he or she should note details regarding the person’s leaving condition, any follow-up actions needed, prescription information, test results and any concerns or side notes. Both the physician and the patient should sign the discharge form in order to show that both agreed on the terms of release and follow-up care.

At any point during the treatment, physicians should make clear note of a patient’s noncompliance or refusal of care. Doing this can show a jury that the patient was responsible for the unfavorable results, and it can shift the burden from the physician.

At the Law Offices of Gutglass, Erickson, Bonville & Larson, we are experienced at providing legal services to physicians and medical personnel facing malpractice charges. That’s why we encourage the practice of keeping good records. As attorneys, we know that written records are valuable pieces of evidence that can make or break a case. Today, if you are a medical care provider who has gotten lax in your documentation, we urge you to re-engage the habit. Doing so could save you in both finances and good standing should the unthinkable happen. And for those who are already facing charges, we encourage you to call us for a free case evaluation. We’ll review your situation and do whatever we can to help you retain your business and defend your reputation.

To schedule your free consultation, contact Gutglass, Erickson, Bonville & Larson today! 


  • There are so many lawsuits in the medical field that all medical personnel have to make sure they are keeping great records. In some ways it is good that they are held at such high standards but not so good they are always afraid of getting sued.

  • It may seem like common sense to some, but keeping accurate medical records is SO important. Both for the practitioner and the patient.

  • I would not be surprised to hear that doctors do not take very good notes on their patients, and of course, that all depends on the doctor. Attention to detail is key in any profession, but could mean life or death in the medical field.

  • Keeping track of the medical records properly sound like a very involved process. It sounds as though there are many many opportunities for error.

  • Allen says:

    Keeping all your records in a safe position is very helpful for both the patients and hospital also. if someone filled a medical malpractice case against the hospital, then all the records and diagnostic reports plays very important role.

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