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What Are the Essentials of Good Documentation?

Attorney June Baker-Laird advises doctors on documentation important to a malpractice defense.

Question: I often hear people say that good documentation is “complete and comprehensive,” but what does that actually mean?

Answer: It is true that the definition of good documentation is in the eye of the beholder. For this reason, we asked top chiropractic malpractice defense attorney June Baker-Laird for her perspective. In this video, she shares the ways in which documentation is essential to a chiropractic malpractice defense.

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Among other things, June Baker-Laird advises doctors to center their documentation on the patient’s history, the patient's actions, and the doctor's observations and treatment:

  • Patient’s history. A doctor’s documentation should focus extensively on the patient’s history—not just what the patient wrote on the form. If something is new, record the reasons the patient is there. Identify the patient’s chief complaint and follow up with questions about who, what, where, why and when. For example, “Where did this neck pain start? Were you skiing? Were you on a black diamond run? Had you been skiing for two to three hours? Were you sitting on the couch watching television?” All of these details are very helpful for defense attorneys who may be looking at the chart two years (or more) later in an effort to defend you.
  • Patient’s actions. Make sure to document what the patient has done to treat the issue, whether they’ve seen their primary care physician, and if they have had X-rays or other tests by another doctor for the same problem or a problem related to the patient’s chief complaint and concern.
  • The doctor’s observations and treatment. Include in your documentation what you diagnosed and the levels and type of your adjustment. Essentially, make sure to note what you did and why you did it. In addition, it is vital to include your follow-up plans for the patient.

For a more detailed look at documentation, see Dr. Stephen Savoie’s article “Common
Documentation Mistakes

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