Document, Document, Document!

The old adage, 'If it isn't written down, you didn't do it,' still rings very true, particularly in the medical malpractice context. The best way to counter an allegation that a provider failed to examine or check something is to point to the records that clearly demonstrate that the opposite is true. The necessity for complete, honest, accurate and legible documentation cannot be over emphasized. This being said, however, it is recognized that documenting every thought may at times be cumbersome and not altogether realistic. To make up for this practical deficiency, it is important to establish clear methods and procedures for doing business. These methods are sometimes referred to as a provider's 'standard operating procedure.' The procedures should be uniformly and consistently applied with each patient encounter.