Basic principles of documentation
The medical record is the best witness to interactions between a physician and a patient. In the record, we’re required to write a “5-C” description of events—namely, one that is:
- correct
- comprehensive
- conscientious
- clear
- contemporaneous.
Avoid medical jargon in the record. Be careful not to use vague terminology or descriptions, such as “mild vaginal bleeding,” “gentle traction,” or “patient refuses and accepts the consequences.” Specificity is the key to accuracy with respect to documentation (TABLE 4).
Editor’s note: Part 2 of this article will appear in the January 2011 issue of OBG Management. The authors’ analysis of L & D malpractice claims moves to a discussion of causation—by way of 4 troubling cases.
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