Telling the Story: The Medical Record

The medical record can prove to be your best defense or biggest downfall when faced with a lawsuit. Medical record documentation is the determining factor in more than 80 percent of malpractice cases, some of which arise years after the ED visit and long after the specifics of the case are forgotten.

EPIC'S Graham Billingham, MD, FACEP President and CEO, Chairman Eduard Boudreau, DO, and Jeanie Taylor, RN, BSN, MS, Vice President, Risk Management discuss the importance of accurate and timely documentation, the common errors made by providers and resulting implications in using emergency department electronic documentation systems.

The medical record itself should read like a story telling about the patient and how you cared for that patient. A good medical record gives the reader, perhaps even years down the road, an understanding of the thought process that went into the decision-making and ultimately the treatment of the patient.

Category:

Education

Tags:

• EPIC
• emergency room
• ER
• emergency department
• ED
• medical record
• story