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As a Doctor of Chiropractic, you strive to provide your patients the best of care, but good intentions aren’t enough. One of the most common areas doctors can fall short is documentation.
These types of mistakes can put your practice at risk in the event of a malpractice allegation. Plus, with the transition to electronic health records, many doctors are facing issues not encountered with paper records.
You are served with legal documents stating that a former patient is suing you for malpractice. Or, perhaps you receive a letter from the patient's attorney advising you of a claim against you. Should you attempt to "clean up the records"?
Question: I am planning to move to another state, and I anticipate that my patients will remain with my current chiropractic professional group. While I'm an independent contractor, the patients are mine but are billed under the chiropractic group. Should I bring my patient records with me or leave them with the practice?
Question: I often hear people say that good documentation is “complete and
comprehensive,” but what does that actually mean?
While EHRs have seen a surge in popularity in recent years and have made it easier to see a broader view of a patient's care and medical history, it has not come without risk.
Claims related to a missed or delayed diagnosis are the fastest-growing types of claims but they can be avoided. Let's take a look at how to protect yourself, and your patients.
Good recordkeeping is critical in these litigious times. Consequently, many Doctors of Chiropractic have come to believe that “more is better” when it comes to documentation. However, there are a few "don'ts" in a clinical record that are important to keep in mind.
They've come to see you about one thing, and just before you leave the room you hear, "Oh, by the way, doctor..."
The informed consent discussion gives a doctor the unique opportunity to build rapport and trust with patients. It is a thorough discussion that enables the doctor to educate the patient on the recommended treatment.
Smartphones are so common it's normal to see a patient holding their device during an office visit. But with smartphones a patient can also make voice or even video recordings of that doctor visit. It's easy to do, and you may not even know you are being recorded.
It's been my experience that making the following common documentation mistakes can put your practice at risk in the event of a malpractice allegation.
The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.