Medical Malpractice Litigation
The medical record is the basic legal document in medical malpractice litigation. A poorly written, disorganized record is strong evidence of an incompetent medical care provider. The poorly kept record is not, in itself, proof of negligence on the part of the medical care provider, but it is proof of substandard care. Conversely, 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.