Quality control documentation serves three purposes:

1. It. provides the information needed to intervene in situations where there are quality of care problems.

2. It provides the information that independent auditors (such as the JCAH) need to evaluate the hospital's quality control program.

3. It provides the documentation necessary to defend lawsuits.

These purposes are not mutually exclusive, but they do require different record-keeping techniques. This chapter will deal with the general legal considerations in quality control documentation, including a detailed discussion of the legal status of medical records. The following chapter examines the protection of incident reports and the legal requirements that oversight committees must meet.

The basic question that arises in planning legal strategies for records management is whether the records in question should be protect from discovery in a lawsuit or whether they should be admissible as a defensive document. If it is decided to protect a document, it may be difficult to get that document entered into evidence if it is needed for the defense of a lawsuit. There may also be logistical problems if a hospital attempts to protect too many documents. This can result in the loss of protection for sensitive documents because of the dilution of professional staff attention.

The first part of this chapter addresses the protection of records. This includes a discussion of the attorney-client privilege, the attorney work-product doctrine, and the legal limitations on an attorney administrator. The remainder of the chapter discusses the requirements for ensuring that a document will be admissible in court. Since the most important admissible document is the medical record, this examination is framed in terms of the medical record.