The medical record is the basic legal document in medical malpractice litigation. A well-organized, well-written record is the best defense for the competent health care provider. The poorly written, disorganized record is strong evidence of an incompetent health care provider. The poorly kept record is not, in itself, proof of negligence on the part of the health care provider; but it is proof of substandard care. When a medical malpractice attorney reviews medical records to determine whether the patient has a valid medical malpractice suit, it is the overall quality of the record that the attorney bases his decision on, not just isolated incidents of negligence found in the record. The medical malpractice suits that are easiest to prove are based upon internal inconsistencies in the medical record. An example would be a situation where the physician's progress notes report that the patient was doing well and improving steadily, but the nurses' records indicate that the patient had developed a very high fever and appeared to have a major infection. From the hospital's perspective, such inconsistencies show a breakdown in communication between the nurse and physician.
Another example of this type of communication problem is the medication error. The physician orders a specific drug, or a particular dosage form of the drug, yet the nurse administers a different drug or a different dosage form. The comparison of the physician's orders with the nurse's medication record will reveal the error and provide strong evidence of the nurse's negligence. Proper maintenance of the medical record in accordance with legal requirements and the JCAH standards (the latter aspect to be discussed in a subsequent chapter) is an important part of an effective quality control program.
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