Most medical practices, in particular large ones, have to keep track of a lot of information. Within each patient is a comprehensive medical history, also known as their record. It gives medical providers—quite literally—up-to-the-minute information on a patient’s condition.
Yet, within these records is a lot of room for error. Multiple people can make changes. Conditions might go undiagnosed. Mistakes can happen. Improper reporting, inaccuracies and omissions could lead to actions that harm a patient. When patients experience harm, they might have grounds to sue for malpractice.
The Importance of Accurate Medical Records
When medical mistakes occur, most people want to figure out why they happened. One of the first places they will usually turn is to the medical record. Because of their detailed information, most records can help pinpoint where mistakes occurred. In effect, they can help provide patients with better care. After malpractice claims, accurate records might even help settle the claim.
Nevertheless, inaccurate records might prove liabilities. Should improper recording lead to mistakes, you might find yourself facing a lawsuit. Therefore, your commitment should be to enforce proper record-keeping practices at all times.
Recordkeeping Best Practices
Every medical office likely has its own process for collecting medical records. There are always principles that each practice should enshrine into its ethical standards.
- Monitor the security of all records systems. If you keep paper records, these should remain strictly under lock and key. Your electronic records must have proper cybersecurity protection. All those who have access to records must have the proper credentials.
- Privacy law governs the disclosure of medical records. Ensure that you never release records unless under lawful pretenses. The practice should adapt a multi-step approval process regarding the release of records.
- Always remember that detail is important in medical records. Physicians should rely on their own observation, the observations of other providers, and the observations of the patients to create comprehensive pictures of the person. Most physicians and providers receive comprehensive training on how to accurately report information.
- Keep in mind, doctors may update records. However, they should not attempt to hide or alter information otherwise proven inaccurate. Falsifying records is an extreme breach of medical ethics. Therefore, it does not qualify for medical malpractice insurance coverage.
Conscientious medical providers should institute strict recordkeeping practices. These should reflect established and required industry standards. However, they should also develop, where appropriate, individualized approaches to record keeping. Your goal, at the end of the day, should be to provide the most comprehensive pictures of your patients. If you have any questions about whether something qualifies for medical malpractice insurance, contact us at 800.462.3401.