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MEDICAL RECORDSGood Records

Ironically, the focus on the medical record as a legal document has reduced both its legal and its medical effectiveness. Medical personnel, constantly told that "the good medical record is the best defense," miss the point that the good medical record is valuable only to the extent that it documents the actual rendering of good medical care. A medical record can be legally disastrous if it demonstrates the incompetence of the underlying medical care. Poor documentation is actually an advantage to an incompetent defendant whose best defense is obfuscation. A poor record may prevent the medical care providers from establishing the good care they gave the patient, but a good record is not a substitute for good care.

The confusion between good medical records and good medical care has helped destroy the usefulness of medical records. Many records administrators believe that the more information in the record, the better the record is. Even if this excess information is accurate and well organized, it dilutes the medically necessary information. Physicians and nurses will have difficulty finding medically necessary information in a timely manner. This leads to substandard medical care and potential medical malpractice litigation. Bigger medical records are not better medical records.

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