Documenting 3 Important Factors To Avoid Medical Malpractice Lawsuits

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Documenting 3 Important Factors To Avoid Medical Malpractice Lawsuits

30 July 2015
 Categories: , Blog


Medical malpractice lawsuits can be a nightmare for the doctor that is going through one. One way that doctors are avoiding potential lawsuits is through documentation. The necessary documentation for any medical appointment includes the the treatment plan for a patient and what the patient's expected outcome is. There are three other factors that need to be included in this documentation in order to significantly reduce the chances of being taken to court.

1. Annotate the Diagnosis

First, you are going to need to clarify exactly what you mean by the patient's diagnosis. Some patients are cut and dry cases. For example, a broken bone might be classified as a fracture, and there's little room for error. If you are able to look at the x-ray of a patient's body and see that he or she has a broken bone, then you know that diagnosis for sure. It gets more difficult when there is no single diagnostic test that you can perform.

For example, your patient might have some of the symptoms of lupus. Lupus has a very large number of symptoms, and just because your patient is displaying these symptoms, you won't necessarily know if your patient has lupus for sure until you start treatment. If you have any doubt in your diagnosis, you will need to clarify this on the documentation and make sure that your patient knows that the diagnosis is your very best guess, but might not be the correct deduction.

2. Explain Any Potential Problems With Treatment

For a broken bone, treatment is simple. You set the bone in the correct position and then make sure that it isn't moved until it is totally healed. For other problems, such as mental health issues, the treatment is not as clear. Nobody knows exactly how antidepressants work, but people do know that they affect everyone differently. You need to document that you told your patient that several different antidepressants might need to be tried in order to combat his or her depression. You also need to document that you informed your patient of any negative side effects of any medications that he or she is taking.

3. Document Follow Up Plans

Document that your patient told you that he or she was willing to meet with you in a few weeks or whenever you scheduled your follow up appointment if one was needed. These follow up appointments can be important in order to maintain the patient's health and if he or she does not show up for one, then his or her health might be at risk. Writing down that you discussed plans allows you to prove that you did your duty as a responsible doctor.

For more information, talk to a professional medical malpractice attorney, like those at R.J. Marzella & Associates, P.C.