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Defensible Records

Viewing the medical record from outside, without reference to its role in medical care, leads to the defensible record, one that does not facilitate good care but does contain enough information to allow a plausible defense for the physician's actions. For example, recording a child's height and weight without plotting a growth chart would allow the defense that the physician was aware of the child's development. Plotting the information, however, might have caused the physician to investigate growth retardation and treat underlying medical problems. This would mitigate the child's injury and reduce the probability of litigation.

From the point of view of prevention, the best medical record is one that facilitates good care. If the patient's care is good, the probability of a successful medical malpractice lawsuit is low. If, in addition to facilitating good care, the record fully documents the patient's course and the care provided, then it is unlikely that a knowledgeable plaintiff's attorney will even proceed with a case. This appears to be happening with structured prenatal care records. These are printed medical records with check-offs for all routine prenatal care, combined with extensive patient education handouts. There have been many fewer than expected claims against physicians using these records. (See Chapter 27.) Given the financial and emotional cost of medical malpractice litigation, the best record is the one that convinces a plaintiff's attorney that it is not worth filing a lawsuit.

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